A 65-year-old man comes to the office due to progressively worsening dyspnea and fatigue over the last 2 weeks. His lifestyle is mostly sedentary with limited activities around the house, but he has had dyspnea for the past 3 days while at rest. The patient was diagnosed with lung cancer a year ago and underwent surgical resection followed by chemotherapy. Other medical conditions include chronic kidney disease and hypertension. Temperature is 37 C (98.6 F), blood pressure is 114/70 mm Hg, pulse is 95/min, and respirations are 20/min. Pulse oximetry shows an oxygen saturation of 95% on room air. Lungs are clear to auscultation bilaterally. There are no heart murmurs. Extremities are without edema. Laboratory studies are as follows:
| Complete blood count | |
| Hemoglobin | 10.8 g/dL |
| Platelets | 180,000/mm3 |
| Leukocytes | 7,500/mm3 |
| Serum chemistry | |
| Blood urea nitrogen | 26 mg/dL |
| Creatinine | 2.2 mg/dL |
Chest x-ray is shown in the exhibit. What is the most appropriate next step in management of this patient?
Malignant pericardial effusion | |
Etiology |
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Clinical features |
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Treatment |
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CXR = chest x-ray; GI = gastrointestinal. | |
This patient with a 2-week history of worsening dyspnea and fatigue has an enlarged cardiac silhouette with clear lung fields on chest x-ray. This is most consistent with pericardial effusion and is concerning for malignant effusion given this patient's history of lung cancer.
Lung cancer is the most common primary tumor implicated in malignant pericardial effusion (MPE). Pericardial involvement occurs either by direct tumor extension or metastatic spread through the blood or lymphatics. This often results in subacute (rather than rapid) accumulation of pericardial fluid accompanied by progressive stretching of the pericardium. Therefore, patients may experience only nonspecific symptoms (eg, dyspnea, fatigue) until enough fluid accumulates (typically 1-2 L) to increase intrapericardial pressure and compromise cardiac function (ie, cardiac tamponade).
Transthoracic echocardiography is used to establish the diagnosis of pericardial effusion, estimate effusion volume, and assess for hemodynamic impairment (eg, right atrial and ventricular collapse). Echocardiography can also guide pericardiocentesis, which should be performed to acquire fluid for cytologic analysis whenever MPE is suspected.
(Choice A) CT angiography of the chest can assess for pulmonary embolism (PE), for which immobilization (eg, sedentary lifestyle) and malignancy are risk factors. However, dyspnea due to PE is commonly abrupt (rather than gradual) in onset, and PE would not explain an enlarged cardiac silhouette on chest x-ray. In addition, CT angiography requires intravenous contrast, which is generally avoided in the setting of renal dysfunction (eg, due to chronic kidney disease).
(Choice C) Erythropoietin is used to treat anemia caused by chronic kidney disease. Severe anemia (eg, hemoglobin <7 g/dL) can cause marked dyspnea; however, this patient's mild, chronic anemia is unlikely to explain dyspnea at rest.
(Choice D) Diuretic (eg, furosemide) therapy can treat volume overload in decompensated heart failure. Heart failure can cause fatigue, dyspnea, and cardiomegaly on chest x-ray; however, it is less likely in the absence of pulmonary edema (eg, no crackles on lung auscultation) and peripheral edema.
(Choice E) Pulmonary function studies can evaluate for obstructive or restrictive lung disease. These can cause dyspnea but typically also have associated findings on lung auscultation (eg, wheezing, crackles) and chest x-ray (eg, hyperinflation, increased interstitial markings).
Educational objective:
Malignancy (eg, lung cancer) is a common cause of pericardial effusion, which may appear on chest x-ray as an enlarged cardiac silhouette with clear lungs. Echocardiography is used to confirm the diagnosis, evaluate for signs of subacute tamponade, and guide pericardiocentesis.