A 84 year old woman with hypertension, 2 type diabetes mellitus and chronic renal failure (GFR 30-50 ml).
2005 NSTEMI: LAD and LCX PCI
2006 angina pectoris: distal RCA PCI. LAD and LCX stents no changes
2014 UA: RCA ISR. 1 BMS implantation. Other stents without ISR
Echocardiographia all the time showed good systolic ejection fraction with good wall motions.
In 2014 starts: in ECHO showed a non siginificant pericardial effusion. After coronarographia seen hematuria and anemia.
An urological examination was negative for tumor, but an pelvis CT was done, whith some negative result.
2014.07 gastroscopia: duodenitis erosiva and chronic erosive gastritis was.
colonoscopy: negative
2015.08.03-04 was admited with melena. Gastroscopy and colonoscopy was not showed a point of bleeding. 3 U of blood was transfused.
An echo showed a significant pericardial effusion and a pericardiocentesis was performed. 1200 cc. straw-yellow liquid evacuated. And other day 100 cc.
2015.08.05-12 admited to hospital with anemia for blood transfusion. Colonoscopy was done again. The source of bleeding was not found. A polyp of the Bauchin valve was cut of.
The histology result of the colonoscopy sample not confirmed malignancy.
2016.01.05 Admited agin with huge pericardial effusion and symptoms of HF. 1500 cc straw-yellow liquid evacuated. A pleural effusion was this time and a diagnostic thoracocentesis was done.
The results from the pleural fluid showed a sigillocellulare cc. cells
The CA 125 was elevetad. (95 the normla range upper limit is 35 at our lab)
Pericardial fluid: eosinophil cells, mesothel and lymphoid cells was seen.
An cardiac MR was done with negative result for a autoimmune disease or primer cardiac malignancy.
An chest CT was done: negative for cc.
An abdominal and pelvis MR was done: at the point of obturator in both side an 6 mm diameter lymphaticus nodus was detected. In the corpus of uterus an 8 mm myoma detected (T2)
Tuberculosis negative.
The hemoculture results is negative
2016.04.20 was admited with huge pericardial effusion. 1200 cc bloody liquid was evacuated.
And now 2016.05.31. Again was admited with effort dyspnoe and not a very huge pericardial effusion.
The pericardial effusion sizes was 30-35 mm mostly left side and 25 mm from apex and right side.
The gastroentereologist, onkologist, gynecologist and urologyst do not know the reason of chronic pericardial effusion. Please help, what is the diagnostic option which can use to find the cause of pericardial effusion.
Thank you that you read and help.
Hi, Norbi Gabor
Perhaps there is a problem with the function of the thyroid gland (hypothyroidism)? I think it is necessary to investigate the Hormones (TSH, T4 f)
TSH was 0,47. (the normal value at our lab is 0,4-4). At the ultrasound of the thyreoid gland showed nothing specific.
Спасибо Татьяна, я забыл дописать данные о щитовидной железы. Может еще какие то идеи?
Yes, ideas are not many. You have excluded the main reasons: polyserositis, infectious, autoimmune, metabolic (including uremic genesis?), сancer. However, venerable age, severe anemia and chronic-recurrent pericardial effusion still require exceptions of pericardial mesothelioma or carcinoma. It may be necessary to perform multispiral CT scan and a biopsy of the pericardium, and should continue onco-gynecology-blood-screening
First of all I would appreciate, if we could continue in English, otherwise many of us, including myself, will not be able to participate further in the discussion.
Principal causes of a recurrent pericardial effusion are infections, malignancies, hematological and (auto-) immunological disorders, as already mentioned. Most of them could be ruled out by Your examinations. Propably You should again look for all the different tumor markers in the effusion and also for a viral contamination (PCR). At the end of the day, You should perhaps go for a pericardioscopy to get an impression of the epi- and pericardial surface and other pathologies. In uncomplicated cases, this may be finished by an interventional pericardiocentesis towards the left pleural spce.
In the presence of recurrent pericardial effusion and in accordance with the characteristics that you mention a diagnostic possibility is to consider the pericardial biopsy. In our country, Colombia, this has been very helpful to clarify the diagnosis and treatment options and has also served to make a pericardial window with what has prevented recurrence of pericardial effusion again.
Appreciate this additional idea. A small biopsy may indeed be performed during the pericardioscopy and may add important information.
Thank you for your answers!
I see, that behind to many of done test, we have more ahead to do.
All of you offerd to make biopsy of pericardium and do other test from pericardiall effusion. (e.g. tumor markers and PCR for viral agents)
Should we repeat the CT or MR of chest and abdomen (+pelvis) every 3-6 month to find malignancy? or other biopsy of GI tract?
or can we use PET SCAN in our situation?
PET - CT is surely a good idea. Repeat CT-or MRI-scans make sens, although one would expect a detectable tumor in case of such a longer history of recurrent pericardial effusions, but never say never, so go ahead.
Yes, pericardial biopsy and histology is crucial. You may still keep tuberculosis in mind, depending on how you screened for it initially.
I think a partial pericardiectomy and biopsy will both help symptomatically and will probably give the diagnosis. Malignancy should be high in the differential especially sonce the last effusion was bloody. You can also do a mammography and a thorough skin examination. Please let us know of the progress.
Rainer Moosdorf: you wrote about PCR and virus contamination. Has it relevancy after 6 month or more?
I think so, a viral etiology cannot be ruled out even after that time.
Chronic pericardial effusion, usually the commonest cause is malignancy, uremia and TB.
Pericardial TB is notoriously difficult to diagnose and the yield of PCR of fluid is about 25% while that of biopsy is 40%. Did the cardiac MRI show any calcification of the pericardium?
I would suggest a pericardial biopsy and a pericardial fenestration, which will improve the symptoms.
I see no results on the pericardial fluid analysis, with regards to pH, proteins, LDH and sugar.
Given high CA125, a malignant process is also possible, so I would suggest a 18FDG-SPECT scan to look for an occult malignancy.
Please keep us updated.
For HBP and type 2DM, 84y neoplasic disease is the first hypothesis. In our country (Brasil) tuberculosis is the second in this age. Biopsy clearly is the gold standard. The Mantoux test or Mendel-Mantoux test (also known as the Mantoux screening test, tuberculin sensitivity test, Pirquet test, or PPD test for purified protein derivative) is a screening tool for tuberculosis (TB) - (SORRY, WIKIPEDIA) should be repeated 2 times. Finally a therapeutic test with Rifampicin, isoniazid, pyrazinamide and ethambutol under a judiciously choice for two month woiuld be done
Here is an update: She has a moderate pericardial effusion. She was on Medrol therapy more than 1 year. It was stopped a few days ago. Under medrol therapy there was no pericardial punction. There was no pericardial biopsy. No tumor marker from pericardial effusion was found. And SPECT was not done (there is no option for searching a primer tumor with SPECT in Hungary). She was an 35 GFR.
Dear Dr. Norbi G. Perhaps the cause of pericardial effusion is hypersensitivity to stent components. In retrospect, I can assume that your patient develops an allergic reaction to nickel, which is contained in alloys, stents are made. Given your updates and the clear link of the symptoms with coronary stenting and positive clinical dynamic of Medrol therapy, it is possible to assume also allergic reaction also to a covering of a stent. In my practice there was a similar case.
BR
Tatiyana Vaikhanskaya: The 2 other PTCA was more than 8 years ago and no pericardial or other effusion was detected. The last PTCA was in 2014 with BMS and after we can detecting pericardial effusion. But this is (the last stent) is BMS.
Hello Norbert Gabor
I apologise for entering the discussion so long after you started it!
i read the other entries with great interest including suggestions about TB , most recently by Adail Almeida . I would have guessed that is an excellent suggestion. I assume the patient is now passed away. Was there a post-mortem examination?
Even with low GFR, I wonder about the role of positron emission tomography. That might be helpful for possible diagnoses like TB (?)
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