Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management.

Massive hemoptysis is a time critical airway emergency in the perioperative setting, with an associated mortality exceeding 50%. Causes of hemoptysis in the perioperative setting include procedural complication, coagulopathy, malignancy, chronic lung disease, infection, left-sided cardiac disease, pulmonary vascular disease and autoimmune disease. A rapid and coordinated multidisciplinary response is required to secure the airway, isolate the lung, ensure adequate oxygenation and ventilation, identify the underlying cause and initiate specific systemic, bronchoscopic, endovascular, or surgical treatment. This review examines the etiology, pathophysiology, as well as approach to management and interventions in perioperative massive hemoptysis.

The efficacy and safety of combined therapy with endobronchial tamponade and bronchial artery embolization for massive hemoptysis.

BACKGROUND: Massive hemoptysis is characterized by its life-threatening nature, potentially leading to airway obstruction and asphyxia. The objective of this study was to evaluate the clinical effectiveness of combining endobronchial tamponade with bronchial artery embolization (BAE) in the treatment of massive hemoptysis. METHODS: Between March 2018 and March 2022, a total of 67 patients with massive hemoptysis who underwent BAE were divided into two groups: the combination group (n = 26) and the BAE group (n = 41). Technical and clinical success rates were assessed, and adverse events were monitored following the treatment. Blood gas analysis and coagulation function indicators were collected before and after the treatment, and recurrence and survival rates were recorded during the follow-up period. RESULTS: All patients achieved technical success. There were no significant differences in the clinical success rate, recurrence rates at 3 and 6 months, and mortality rates at 3 months, 6 months, and 1 year between the combination group and the BAE group. However, the hemoptysis recurrence rate at 1 year was significantly lower in the combination group compared to the BAE group (15.4% vs. 39.0%, P = 0.039). No serious adverse events were reported in either group. After treatment, the combination group showed higher levels of arterial partial pressure of oxygen (PaO2), oxygenation index (PaO2/FiO2), fibrinogen (FIB), and D-dimer (D-D) compared to the BAE group (P < 0.05). Multivariate regression analysis demonstrated a significant correlation between combined therapy and hemoptysis-free survival. CONCLUSION: Combination therapy, compared to embolization alone, exhibits superior efficacy in improving respiratory function, correcting hypoxia, stopping bleeding, and preventing recurrence. It is considered an effective and safe treatment for massive hemoptysis.

Uremic Pericarditis and Cardiac Tamponade Resolving With Intensive Hemodialysis.

We present an interesting and complex case of cardiac tamponade due to uremic pericarditis (UP), resolving with intensive hemodialysis (HD). HD should be considered as first line management for patients with UP and pericardial effusion. Intensification of HD should be considered based on clinical presentation and severity of presentation.

Masquerade of an emergency: cardiac tamponade as a deceptive presentation of primary cardiac diffuse large b-cell lymphoma-a case report.

Background: Primary cardiac diffuse large B-cell lymphoma (CDLBCL) is an exceptionally rare entity, estimated to represent less than 1% of all primary cardiac tumours. In this case report, we emphasize the diagnostic importance of multimodality imaging and the need for additional procedures, such as tissue biopsy, in a case with a primary cardiac lymphoma presenting with cardiac tamponade. Case summary: An 80-year-old male was admitted to the emergency department with a life-threatening tamponade demanding immediate sternotomy. Pre-operative echocardiography unveiled pericardial effusion and a thickened apex. While computed tomography ruled out an aortic dissection, surgery revealed an unexpected vascular-rich mass at the right ventricle and apex, too perilous for biopsy. Post-operative imaging misinterpreted this mass as a benign haematoma. Subsequently, the patient was admitted to the intensive care unit, but after a conservative treatment strategy, the patient died. An autopsy revealed a primary CDLBCL. Discussion: This case demonstrates the deceptive nature of primary CDLBCL, often complicated by cardiac tamponade. It underscores the pivotal role of pathologic assessment, even amidst the perils of sternotomy, to determine the origin of abnormal cardiac masses. A heightened awareness among physicians is imperative, for such elusive diagnoses may slip by, with potentially fatal outcomes.

Aortic Dissection Complicated by Coronary Malperfusion and Tamponade: A Case Report.

Aortic dissection is rare and often presents with atypical symptoms. We describe a case of a patient with acute aortic dissection involving the coronary arteries, complicated by pericardial tamponade, and discuss findings using point-of-care ultrasound, diagnostics, and treatment of this condition.

COVID-19 Presenting as Encephalitis and Myopericarditis: A Report of a Rare Case.

COVID-19 might present with a wide range of clinical manifestations, from mild respiratory distress to severe multi-organ dysfunction. We present a unique case of complex COVID-19 presentation in a 45-year-old female who initially developed general symptoms such as fever, cough, headache, and weakness, which escalated to coma, requiring intubation and ICU admission. A brain MRI revealed lesions compatible with encephalitis, the cause of which remained unexplained after an in-depth clinical, laboratory, and imaging investigation. While in the ICU, the patient also developed cardiac tamponade, requiring pericardiocentesis, and atypical electrocardiographic changes. After treatment with steroids, her condition improved, and the patient was extubated and transferred to the ward. Upon checkup, cardiac MRI revealed fibrous tissue in the inferior cardiac wall and the adjacent intraventricular septum. In the absence of an alternative diagnosis, it might be important to consider the central nervous system and cardiac involvement in patients with COVID-19.

Pericardiocentesis in Severe Pulmonary Arterial Hypertension Guided by a Pulmonary Artery Catheter.

Patients, often with underlying rheumatologic disease, may present with pericardial effusions in the setting of pulmonary hypertension (PHTN). Pericardial drainage in PHTN is associated with significant morbidity and mortality. We describe a patient with PHTN who developed cardiac tamponade that was managed safely and effectively with pulmonary artery catheter-guided pericardiocentesis.

Unveiling a Unique Presentation of Superior Vena Cava Syndrome Succeeding a Traumatic Motor Vehicle Crash and Implantable Cardioverter-Defibrillator Lead Placement.

Superior vena cava (SVC) syndrome, once a rarity, has seen an uptick in cases with diverse origins. While this disease process is clinically diagnosable, imaging modalities and tissue biopsies further refine interventions. The clinical presentation includes but is not limited to edema of the arms, neck, and head, facial plethora, cyanosis, and or distention of subcutaneous vessels. SVC syndrome can be attributed to extrinsic compression or thrombosis in many cases. If symptoms are not life-threatening, the overall morbidity is based on the underlying root cause. Few cases have been reported with associated death due to epistaxis. However, the obstruction itself can be initially asymptomatic and then slowly progress over months to years. This case report highlights a distinct instance of SVC syndrome with notable risk factors: implantable cardioverter defibrillator placement and prior cardiac trauma status post-intervention.

Unveiling the Shadows: A Rare Encounter With Cardiac Tamponade Following Influenza B in a Young Female.

Influenza B infection, although primarily recognized for respiratory symptoms, can lead to rare but severe cardiac complications such as pericardial effusion and cardiac tamponade. We present a case of a 33-year-old female with morbid obesity who initially exhibited flu-like symptoms, was subsequently diagnosed with influenza B infection, and was discharged with symptomatic treatment. Despite initial discharge, she returned with worsening weakness, gastrointestinal symptoms, and shortness of breath. Imaging studies confirmed pericardial effusion with early signs of tamponade, necessitating an emergent intervention. The patient underwent subxiphoid pericardial window and fluid removal, followed by colchicine treatment to prevent recurrence. Our case highlights the importance of recognizing and promptly managing rare influenza-related complications, particularly in patients without significant comorbidities. It underscores the value of a proactive approach, utilizing point-of-care ultrasound and echocardiography for early diagnosis and intervention to mitigate mortality and morbidity risks associated with pericarditis and cardiac tamponade secondary to influenza B.

Cardiac Tamponade as The Initial Presentation of Childhood Systemic Lupus Erythematosus: A Case Report.

Systemic Lupus erythematosus (SLE) is an autoimmune disorder characterized by the proliferation of autoantibodies and immune dysregulation resulting in damage to many body organs. Pediatric SLE usually presents with fever, joint pain, rashes, and lupus nephritis. It is uncommon to have large pericardial effusions in children with SLE and cardiac tamponade as the initial presentation of SLE is even rarer. An 11-year-old female presented to our Children Emergency Unit with fever and fast breathing for two weeks, bilateral leg swelling of four days, and cough of two days duration. She was acutely ill, tachypneic, and dyspneic with marked orthopnea, bilateral leg edema, and raised JVP. She was tachycardic with a diffuse apex beat. Chest X-ray showed a large globular heart. 2D-Echocardiography showed a large circumferential pericardial effusion with a dilated non-collapsing IVC and diastolic collapse of the right ventricle. She had a pericardiotomy done and 650mls of serous pericardial fluid was drained. The inner pericardium had a fibrinoid exudate with a "bread-and-butter" appearance. Pericardial fluid cytology showed no malignant cells while pericardial biopsy showed suppurative granulomatous inflammation. Antinuclear antibody (ANA) was strongly positive. The patient was managed with corticosteroids, colchicine, and hydroxychloroquine, and has remained stable on follow-up. While cardiac tamponade as an initial presenting complaint in SLE is rare, it is important that children presenting with large pericardial effusions and tamponade be evaluated for rheumatologic disorders. This can be crucial to revealing the correct diagnosis and instituting appropriate care.

A Rare Occurrence of Chylopericardium in a Case of Anterior Mediastinal Mass.

A middle-aged gentleman presented with dyspnea and hypotension, accompanied by an anterior mediastinal mass infiltrating the anterior chest wall and a moderate to large pericardial effusion, which upon evaluation revealed chylous fluid. Further investigation diagnosed him with right lung adenocarcinoma infiltrating the chest wall, staged at T4N3M1. The patient subsequently developed cardiac tamponade, necessitating immediate medical intervention. Management of the patient's cardiac tamponade involved pericardiocentesis via an indwelling pericardial catheter, allowing continuous drainage of the chylous fluid. Additionally, the patient was placed on a medium-chain triglyceride diet (MCTD) to reduce chyle production. These interventions resulted in significant symptomatic improvement, stabilizing the patient's hemodynamic status, and alleviating the immediate life-threatening condition. This case highlights the clinical challenges posed by rare presentations such as chylopericardium secondary to malignancy and emphasizes the importance of comprehensive diagnostic evaluation and prompt therapeutic management. The successful outcome, achieved through a combination of pericardial drainage and dietary modifications, underscores the critical role of a conservative approach in managing complex oncological cases with acute complications.

Purulent Pericarditis in End-Stage Renal Disease: A Rare Case of Citrobacter freundii Infection.

BACKGROUND: Purulent pericarditis is a rare but life-threatening condition, particularly challenging when it occurs in immunocompromised individuals. CASE REPORT: We present the case of a 68-year-old man with end-stage renal disease who developed purulent pericarditis secondary to Citrobacter freundii infection. Despite initial challenges in diagnosis and management, the patient showed a favorable response to antibiotic therapy. CONCLUSIONS: This case highlights the importance of prompt recognition and treatment of purulent pericarditis, especially in patients with underlying immunosuppression and comorbidities.

Untreated Primary Hypothyroidism Manifesting as Cardiac Tamponade.

Hypothyroidism is a condition characterized by low thyroid hormone levels that can affect multiple organ systems with varying symptomatology. Common cardiac manifestations of hypothyroidism include bradycardia and decreased cardiac output. Pericardial effusion can also occur as a result of the condition and rarely can progress to cardiac tamponade. Patients with cardiac tamponade occurring as a result of underlying hypothyroidism can present atypically compared to those experiencing cardiac tamponade due to other causes. Patients with cardiac tamponade as a result of underlying hypothyroidism may present as minimally symptomatic with stable vital signs. Close monitoring of patients with pericardial effusions with underlying hypothyroidism is essential to permit early diagnosis and treatment of the condition. We outline the case of a 73-year-old male presenting with cardiac tamponade due to underlying hypothyroidism necessitating an urgent pericardial window.

Case report: Clinical features of pediatric acute myeloid leukemia presenting with cardiac tamponade: a case series study and literature review.

Objective: This study aims to elucidate the clinical features observed in cases of pediatric acute myeloid leukemia (AML) initially presenting with cardiac tamponade and to share treatment experiences. Materials and methods: Five pediatric patients were initially diagnosed with AML accompanied by cardiac myeloid sarcoma (MS). The diagnosis was established by examining our hospital records and reviewing pertinent literature from 1990 to July 2023, accessible through MEDLINE/PubMed. We comprehensively assessed the clinical characteristics and treatment modalities employed for these patients. Result: Five pediatric patients presented with acute symptoms, including shortness of breath, malaise, cough, and fever, leading to their hospitalization. Physical examination revealed irritability, hypoxia, tachypnea, tachycardia, and hypotension. Initial detection utilized chest X-ray or echocardiogram, leading to subsequent diagnoses based on pericardial effusion and/or bone marrow examination. Two patients received chemotherapy at the time of initial diagnosis, one with cytarabine and etoposide, and the other with cytarabine and cladribine. Post-treatment, their bone marrow achieved remission, and over a 2.5-year follow-up, their cardiac function remained favorable. Unfortunately, the remaining three patients succumbed within two weeks after diagnosis, either due to receiving alternative drugs or without undergoing chemotherapy. Conclusion: This is the first and largest case series of pediatric AML patients with cardiac MS, manifesting initially with cardiac tamponade. It highlights the rarity and high mortality associated with this condition. The critical factors for reducing mortality include identifying clinical manifestations, conducting thorough physical examinations, performing echocardiography promptly, initiating early and timely pericardial drainage, and avoiding cardiotoxic chemotherapy medications.

Retrosternal hematoma causing torsade de pointes after coronary artery bypass graft surgery; a case report.

Myocardial infarction is among the top causes of mortality worldwide. Survivors may also experience several complications. Infarct-related torsade de pointes (TdP) is an uncommon complication. In the context of myocardial infarction, coronary artery bypass graft (CABG) surgery is the prevalent therapeutic modality associated with several early and late complications. Ventricular tachyarrhythmias, including TdP, because of electrical inhomogeneity, would potentially be a lethal complication of CABG. Here, we report the occurrence of medically intractable TdP in the presence of an uncommon case of a post-CABG retrosternal hematoma. Arrhythmia was properly resolved after hematoma removal surgically. It showed the possibility of a "cause and effect" relationship between these two complications. This unique case emphasizes the post-CABG medically-resistant TdP, considering the mechanical pressure effect of retrosternal hematoma that stimulates this potentially malignant arrhythmia, especially in the absence of electrolyte disturbances and evident symptoms of ongoing ischemia.

"A Double Twist" Presentation - A Case Report of Purulent Cardiac Tamponade following a Rare Complication of Small-Cell Lung Cancer Radiotherapy.

Background: Small cell lung cancer is an aggressive tumor with a poor prognosis that requires prompt treatment. While radiotherapy may enhance survival when superior vena cava syndrome is present, radiation therapy-induced pericardial disease can be a potential complication. Case Report: A 55-year-old man, who recently underwent radiotherapy for stage IV small-cell lung cancer complicated by superior vena cava syndrome, presented with chest pain and dyspnea. In the emergency room, he was dyspneic, hypotensive, and tachycardic. Pulmonary auscultation revealed the absence of lung sounds on the right. The initial electrocardiogram showed ST-segment elevation in lateral leads and in lead DII, with reciprocal changes in lead DIII. A bedside transthoracic echocardiogram revealed cardiac tamponade and emergent pericardiocentesis was performed, removing 500 ml of purulent fluid, resulting in an immediate clinical improvement. Thoracentesis was also performed, showing no empyema. Large spectrum empirical antibiotic therapy was started. Cultures from the pericardial fluid and peripheral blood grew multi-sensitive Streptococcus pneumoniae. Cytological analysis of the pericardial fluid was consistent with infection. The patient improved after 2 weeks of targeted antibiotic therapy and underwent the first cycle of chemotherapy. He was discharged with an early scheduled pulmonology appointment. Conclusions: Although the most common causes of pericardial effusion in lung cancer are malignant, non-malignant etiologies should also be considered. This patient had an infectious pericardial effusion most probably due to a pericardial-mediastinal mass fistula caused by radiotherapy. This was a diagnostic challenge, both in the emergency room as well in the inpatient setting. LEARNING POINTS: Small cell lung cancer is a fast-growing cancer that exhibits aggressive behavior.In patients with lung cancer, malignant pericardial effusions are more common than non-malignant ones.Purulent pericardial effusions, especially those due to lung cancer, are rare in developed countries with very few reports in the literature.

Age-stratified patterns in clinical presentation, treatment and outcomes in acute pericarditis: a retrospective cohort study.

BACKGROUND: There are limited data on acute pericarditis according to different age groups. The aim of this study is to investigate the role of age-related features in clinical characteristics, management, and outcomes of acute pericarditis, with a focus on the geriatric population. METHODS: Patients with a first episode of acute pericarditis were consecutively enrolled between January 2014 and June 2022, and divided into four groups according to age (G1: 18-35 years; G2: 35-55 years; G3: 55-75 years; G4: >75 years). Clinical characteristics and medical therapy were recorded at baseline, and during follow-up. RESULTS: A total of 471 patients (median age 56.3 (IQR 33-73) years, 32.3% women) were included. Younger age (G1-G2-G3) was associated with a higher frequency of chest pain, pericardial rubs (p<0001), ECG changes (p=0.002) and were more commonly treated with colchicine (p<0.001), and non-steroidal anti-inflammatory drugs (p=0.006). Older patients (G4) depicted more commonly dyspnoea, pericardial/pleural effusion (p=0.007) and were more often treated with corticosteroids (p=0.037). A secondary cause of pericarditis was detected in 128/471 (27.2%) patients. Older patients were more commonly hospitalised and had a complicated course with new-onset atrial fibrillation (p<0.001) and cardiac tamponade (p=0.005), compared with younger patients, who presented more recurrences (respectively G1: 43.0%, G2: 34.7%, G3: 28.2% and G4: 16.2%; p<0.001). After multivariable analysis, younger age remained the strongest independent predictor for recurrences (HR 3.23, 95% CI 1.81 to 5.58, p<0.001). CONCLUSION: Older age is associated with less recurrences of pericarditis, but more severe complications with need for hospitalisation.

Blast from the Past: Acute Myeloid Leukemia Presenting with Cardiac Tamponade.

Acute Myeloid Leukemia (AML) is a life-threatening illness that requires prompt diagnosis and often immediate treatment. It can present in a variety of manners but most commonly is associated with fevers, fatigue, shortness of breath, or infection. Extramedullary leukemia is a less common finding upon initial presentation, but includes dermatologic manifestations, including leukemia cutis, and rarely, large mass-like presentations known as myeloid sarcomas. While leukemic infiltration of organ systems is a well-described phenomenon, cardiac tamponade is a rare form of presentation. Herein we describe a 58-year-old man with a recent hospitalization for idiopathic cardiac tamponade who re-presented to the hospital with worsening dyspnea and fevers. He was found to have a recurrent pericardial effusion with features concerning for tamponade, as well as worsening thrombocytopenia and macrocytic anemia. Bone marrow biopsy revealed 24% myeloblasts, confirming the diagnosis of AML. Notably, his cardiac symptoms improved with treatment of his leukemia. To our knowledge, this is one of only a few cases of AML with cardiac tamponade as the initial presentation.