Cardiac sarcoidosis: a case report and review of the literature

Massive pericardial effusion is rarely the sole clinical presenting symptom of sarcoidosis. Herein we report a case of recurrent pericardial effusions requiring surgical intervention secondary to sarcoidosis. A review of the literature regarding the prevalence/histopathology, the role of endomyocardial biopsy, the use of cardiac magnetic resonance imaging, and the utility of steroid based treatments in the management of cardiac sarcoidosis is discussed.

A modern approach to tuberculous pericarditis

The human immunodeficiency virus (HIV) epidemic has been associated with an increase in all forms of extrapulmonary tuberculosis including tuberculous pericarditis. Tuberculosis is responsible for approximately 70% of cases of large pericardial effusion and most cases of constrictive pericarditis in developing countries, where most of the world's population live. However, in industrialized countries, tuberculosis accounts for only 4% of cases of pericardial effusion and an even smaller proportion of instances of constrictive pericarditis. Tuberculous pericarditis is a dangerous disease with a mortality of 17% to 40%; constriction occurs in a similar proportion of cases after tuberculous pericardial effusion. Early diagnosis and institution of appropriate therapy are critical to prevent mortality. A definite or proven diagnosis is based on demonstration of tubercle bacilli in pericardial fluid or on histologic section of the pericardium. A probable or presumed diagnosis is based on proof of tuberculosis elsewhere in a patient with otherwise unexplained pericarditis, a lymphocytic pericardial exudate with elevated biomarkers of tuberculous infection, and/or appropriate response to a trial of antituberculosis chemotherapy. Treatment consists of 4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months regardless of HIV status. It is uncertain whether adjunctive corticosteroids are effective in reducing mortality or pericardial constriction, and their safety in HIV-infected patients has not been established conclusively. Surgical resection of the pericardium is indicated for those with calcific constrictive pericarditis or with persistent signs of constriction after a 6 to 8 week trial of antituberculosis treatment in patients with noncalcific constrictive pericarditis.

[A difficult case of esophageal and gastric double cancer with pleural and pericardial effusion following chemo-radiotherapy (CRT)]

A 70-year-old man was presented with esophageal and gastric cancer pointed by his personal doctor in November 2002. Both of the esophageal and gastric cancer were diagnosed as multiples with cStage II and cStage IA, respectively. In consideration of the patient's quality of life (QOL), chemo-radiotherapy (CRT) for esophageal cancer was preceded, and then total gastrectomy was done. Although esophageal cancer was responded as being complete response (CR), 14 courses of FP therapy were added as supportive chemotherapy. Ten months following CRT, pericardial effusion was noticed, so that pericardiocentesis was performed. Also diuretic has been administered up to the present. Nineteen months following CRT, pleural effusion was noticed and thoracentesis was performed several times into both of the pleural cavities, and that was depending on the degree with OK-432 infusion. Consequently, the patient has been controlled well. As a treatment for esophageal and gastric double cancer, we chose CRT rather than esophagectomy because of the excessive invasiveness. Despite of CR, we have had a difficulty with pleural and pericardial effusions due to the late toxicity of radiotherapy. We need to pay attention to the late toxicity in the case of long-term survival following CRT.

Massive pericardial effusion in an early gestational fetus having intrapericardial diaphragmatic hernia

Intrapericardial diaphragmatic hernia is a very rare phenotype of congenital diaphragmatic hernia. Twelve cases of this condition have been reported under the age of 1 year since 1981, and in only four cases were abnormal findings observed antenatally. We report a case of a fetus with this disease in which pericardial effusion was noted in an earlier gestational age than any other previously reported cases. A 35-year-old pregnant woman was referred to our center at 16 weeks' gestation. Ultrasound revealed that the bilateral lungs of the fetus were very small due to the compression by massive pericardial effusion. Pregnancy was terminated at 18 weeks, and autopsy of the stillborn baby revealed intrapericardial diaphragmatic hernia and cardiac aneurysm of the right ventricle. In conclusion, when pericardial effusion is observed in a fetus, intrapericardial diaphragmatic hernia, a very rare type of congenital diaphragmatic hernia, must be included in a differential diagnosis.

[Uterine cervical carcinoma and pericardial effusion]

A 64-year-olf woman has been treated by chemotherapy for a uterine cervical carcinoma with known pathological lymph nodes in the abdomen and in the thorax. She is admitted in our Intensive Care Unit for fever and cardiac tamponade attributed to a large pericardial effusion. No diagnostic could be concluded from the analysis of the liquid or the pericardial biopsy. Complementary investigations are performed and the differential diagnosis of pericardial effusion is discussed in the context of a neoplastic disease.

Chylothorax and chylopericardium as the initial clinical manifestation of Behcet’s disease

Behcet's disease (BD) is a chronic relapsing systemic vasculitic disorder affecting the arteries, veins, and vessels of any size. Large vein thrombosis in BD is not commonly developed and most commonly observed in the veins in the lower extremities and inferior or superior vena cava. In this report, a 18-year-old male patient with large vein thrombosis involving superior vena cava was presented. He was treated due to chylothorax and chylopericardium with SVC syndrome before diagnosis of BD. SVC thrombosis complicated by chylothorax and chyolpericardium can be a rare presenting initial symptom of BD.

Canine pericardial effusion: pathophysiology and cause

Pericardial effusion is the abnormal accumulation of fluid in the pericardial space. As the fluid volume and intrapericardial pressure increase, cardiac tamponade can develop. The most common causes of pericardial effusion include cardiac hemangiosarcoma, idiopathic pericardial effusion, and chemodectoma. Understanding the underlying cause is important in providing treatment recommendations and an accurate prognosis.

Activated coagulation factors in human malignant effusions and their contribution to cancer cell metastasis and therapy

We have shown that the thrombin G-protein coupled receptors (GPCR) designated as protease-activated receptors (PAR-1) are expressed in primary cancer cells isolated from peritoneal and pleural malignant effusions. Here, our main goal was to evaluate several coagulation and thrombin activation effectors and markers in a series of 136 malignant effusions from cancer patients with gastrointestinal, lung and mammary carcinomas. All these patients present a highly activated coagulation system in blood and their malignant effusions, as indicated by high levels of prothrombin F1.2 fragments and D-dimers. Notably, we detected in the effusions all the coagulation factors of the tissue factor pathway inducing thrombin activation, namely factors VII, V, X and II, as well as high VEGF levels and IGF-II in mature and precursor forms. Fibrin clot formation also correlated with higher levels of free ionized calcium (iCa), suggesting that iCa and its binding protein albumin are regulatory factors for fibrinogenesis in effusions. Consequently, thrombin, VEGF and IGFII appear to converge in the promotion of survival and invasivity of the metastatic cancer cells from blood to the malignant effusions. Thus, we add new insights on the interconnections between blood coagulation disorders in cancer patients and thrombin activation in malignant effusions, including their functional interaction with PAR in metastatic cancer cells. Based on these data we propose to counteract the metastatic cascades by targeted invalidation of key effectors of the coagulation system. Therefore, potential therapeutic approaches include the application of thrombin protease inhibitors, VEGF-blocking antibodies, and drugs targeting the VEGF and thrombin signaling pathways, such as tyrosine kinase or GPCR inhibitors.

[Primary effusion lymphoma complicating cardiac tamponade: a case report]

A 76-year-old woman was admitted to our hospital because of exertional dyspnea and leg edema during the previous month. Her systolic blood pressure on admission was 80 mmHg with 12 mmHg of pulsus paradoxous, and her pulse rate was 110 beats/min. Chest radiography revealed marked cardiomegaly and echocardiography showed massive pericardial effusion mainly behind the left ventricle and collapse of the right ventricle. The initial diagnosis was pericardial tamponade. Pericardiocentesis and pericardial drainage revealed bloody pericardial effusion. After drainage, her vital signs improved and her symptoms immediately disappeared. The cytological analysis of the pericardial effusion revealed numerous lymphoma cells. Computed tomography of the neck, chest and abdomen showed no evidence of tumor masses, lymph node enlargement, or hepatosplenomegaly. Infectious disease, collagen disease and aortic dissection were excluded. The final diagnosis was primary effusion lymphoma. The prognosis of primary effusion lymphoma is generally unfavorable because it is frequently accompanied by immunodeficiency disease. However, there was no human immunodeficiency virus infection in this patient. Fortunately, the effect of chemotherapy was excellent and the patient is doing well 1 year after the diagnosis.

Use of an insect cell culture growth medium to isolate bacteria from horses with effusive, fibrinous pericarditis: A preliminary study

Effusive, fibrinous pericarditis is an uncommon disease entity in horses. In 2001, pericarditis occurred in conjunction with an epizootic in central Kentucky that was associated with exposure to eastern tent caterpillars (ETCs). Bacterial isolation from equine pericardial fluid samples was attempted using an insect cell culture growth medium (ICCGM). Using previously cultured, stored frozen samples from four horses with fibrinous pericarditis, inoculation of 10% blood agar plates yielded no growth, whereas simultaneous inoculation of ICCGM resulted in the isolation of Proprionibacterium acnes, Staphylococcus equorum, a Streptococcus sp. and Pseudomonas rhodesiae from pericardial fluid samples. A similar or novel caterpillar-associated bacteria was not identified; however, use of an ICCGM might enhance isolation of bacteria from equine pericardial fluid.

Tenecteplase for Malignant Pericardial Effusion

Pericardial effusions may necessitate placement of a catheter into the pericardial space for continuous drainage. If the effusion material is fibrinous or loculated, drainage may slow or cease over time, allowing reaccumulation. Limited data exist to guide the selection of a fibrinolytic agent and the most appropriate dose. We report the case of a 79-year-old woman with malignant pericardial effusion who responded to intrapericardial administration of tenecteplase to facilitate drainage. The patient received three doses of tenecteplase--15 mg, 7.5 mg, and 7.5 mg--over 3 days, resulting in significant drainage. No adverse effects were noted except for a transient episode of hemodynamically stable atrial fibrillation. Use of fibrinolytic agents to facilitate pericardial drainage may offset the need to repeatedly replace the catheter if flow subsides despite continued presence of fluid in the pericardial space.

[Pericardial cytopathology]

Cytopathology diagnosis of three hundred and thirty three pericardial effusions performed between September 1999 and August 2006 were systematically analyzed and compared with the biopsy in 71 cases. We described the clinical circumstances, the etiologies, the cytomorphologic features of the effusions, the role of liquid based cytology and ancillary studies such as immunocytochemistry and the sensitivity of cytopathology compared with histopathology. Among the 57 pericardial tumors, 51 (89%) were metastatic carcinomas--included 42 (73%) adenocarcinomas--, 5 (9%) were malignant lymphomas and one (2%) was a malignant mesothelioma. Cytology of pericardial effusion with ancillary studies enables rapid cytodiagnosis as specific as histodiagnosis provided by biopsy.

Lyme borreliosis and multiple sclerosis are associated with primary effusion lymphoma

Multiple sclerosis (MS) is a chronic disease of the central nervous system characterized by chronic inflammation and demyelination. Studies suggested that the viral, especially Epstein-Barr virus infection, and bacterial infections, especially Borrelia burgdorferi infection, play a role in etiology of MS. MS prevalence parallels the distribution of the Lyme disease pathogen B. burgdorferi. Criteria used for diagnosis of MS can also be fulfilled in other conditions such as Lyme disease, a multisystem disorder resulting from infection by the tick-borne spirochete, B. burgdorferi. In the late period of Lyme disease demyelinating involvement of central nervous system can develop and MS can be erroneously diagnosed. A Lyme borreliosis can mimick central nervous system lymphoma. Also, B. burgdorferi has been implicated not only in etiology of MS, but also in etiology of lymphoma. Studies suggested that there is an increased risk of non-Hodgkin lymphoma in patients, who had a history of autoimmune diseases such as MS and that both non-Hodgkin's lymphomas and Hodgkin's disease were associated with Epstein-Barr virus infection. A small group of lymphomas called primary effusion lymphomas (PEL) is a recently individualized form of non-Hodgkin's lymphoma (WHO classification) that exhibit exclusive or dominant involvement of serous cavities, without a detectable solid tumor mass. These lymphomas have also been linked to Epstein-Barr virus and human herpes virus type 8 infections but virus negative cases have been described. Therefore, we propose that MS and neuroborreliosis are linked to central nervous system primary effusion lymphomas. As a first step in confirming or refuting our hypotheses, we suggest a thorough study of CSF in the patients suspected for the diagnosis of MS and Lyme borreliosis.

Novel BLIMP1/PRDM1 gene mutations in B-cell lymphoma

B lymphocyte-induced maturation protein 1 (BLIMP1)/PR domain containing 1 with zinc finger domain (PRDM1) is a transcriptional repressor with a SET domain and Kruppel-type zinc fingers. BLIMP1/PRDM1 is expressed in a subset of germinal center B cells and in all plasma cells, and it is required for terminal B-cell differentiation. Mutations of the BLIMP1 gene have been reported in patients with diffuse large B-cell lymphoma. Here, we describe novel mutations in the BLIMP1 gene in 2 of 15 (13%) cases of B-cell lymphoma (two cases of primary effusion lymphoma and 13 cases of diffuse large B-cell lymphoma). A tandem 10-base pair duplication (5'-GCTGAGTTTG-3') was found in exon 2 of the BLIMP1 gene in primary effusion B-cell lymphoma. We also found in diffuse large B-cell lymphoma a single base substitution in exon 6 (1747C-->T) that results in a somatic nonsense mutation (Q583X). These findings indicate that mutational analysis of the BLIMP1 gene may be useful for characterizing the molecular basis of B-cell lymphoma.

Idiopathic primary chylopericardium in a dog

CASE DESCRIPTION

A 7-year-old spayed female Labrador Retriever was evaluated because of pericardial effusion.

CLINICAL FINDINGS

The dog had a history of decreased appetite and exercise intolerance of 3 days' duration. Thoracic radiography performed by the referring veterinarian revealed a large cardiac silhouette. Heart sounds were muffled. Echocardiographic findings were indicative of severe pericardial effusion with cardiac tamponade; no pleural effusion was identified. Pericardiocentesis yielded a considerable amount of chylous fluid. A diagnosis of chylopericardium in the absence of pleural effusion was made.

TREATMENT AND OUTCOME

Conservative management was not effective, and subtotal pericardectomy and thoracic duct ligation were recommended. Surgery was postponed by the owners for 25 days, at which time the dog had both chylopericardium and chylothorax. The dog underwent subtotal pericardectomy and thoracic duct ligation; to delineate the thoracic duct, intraoperative lymphangiography was performed by injection of a radiopaque contrast agent directly into a mesenteric lymph node and subsequent injection of methylene blue solution into another mesenteric lymph node. Surgical treatment resulted in complete resolution of the clinical signs and pleural effusion.

CLINICAL RELEVANCE

To the authors' knowledge, this is the first report of the development of chylopericardium prior to development of chylothorax in a dog. Treatment with thoracic duct ligation and pericardectomy resulted in complete resolution of the effusion and clinical signs.

Pericardial involvement as an atypical manifestation of giant cell arteritis: report of a clinical case and literature review

PURPOSE

Pericardial effusion has been known to be a rare manifestation of giant cell arteritis. During the last six decades, only 24 cases have been cited in the literature. In this report, we describe the case of a patient presenting with nonspecific symptoms and development of pericardial effusion.

PROCEDURES AND FINDINGS

A 71-year-old woman was admitted to the hospital with low-grade fever, exertion breathlessness, atypical diffuse muscular pain, and weight loss over a period of about 5 weeks. Pericardial effusion and giant cell arteritis were diagnosed by echocardiography and left temporal artery biopsy, respectively. Treatment with corticosteroids resulted in remarkable improvement of symptoms and complete remission of pericardial effusion. One year after admission, the patient remained in a stable good condition, under low steroid maintenance dosage.

CONCLUSIONS

The diversity of clinical manifestations (such as pericardial effusion) in such a potentially severe disease should alert the physician to prompt diagnosis and treatment in view of impending irreparable vascular damages, even in cases in which the initial presentation is quite uncommon.

Pericardial fat mimicking pericardial effusion on two-dimensional echocardiography

A 78-year-old overweight woman with diabetes mellitus, bronchial asthma, and Sheehan's syndrome on chronic steroid therapy presented with mild short-lived hematemesis, significant hypotension disproportionate to the degree of bleeding and radiographic evidence of cardiomegaly. Endoscopy showed duodenal ulcer. During evaluation of the unexplained brief hypotension and cardiomegaly, 2D-echocardiogram demonstrated anterior and posterior echo-free spaces consistent with large pericardial effusion (PE). However, subsequent elective surgical pericardiotomy unexpectedly revealed large amounts of pericardial fat. Pericardial fat was also noted on magnetic resonance imaging of the chest. Our case illustrates a potential pitfall of 2D-echocardiography in the diagnosis of PE.

Inflammation, ECG changes and pericardial effusion: whom to biopsy in suspected myocarditis?

The role of endomyocardial biopsies in patients with clinically suspected acute myocarditis, myocarditis in the past, and dilated cardiomyopathy is discussed controversially. In fact, it is still under discussion whether information obtained from endomyocardial biopsies is relevant for further clinical decisions. Therefore this Critical Perspective will deal with the question, which patient should undergo endomyocardial biopsy investigations for an etiopathogenic differentiation of the disease and for the possible choice of immunomodulatory treatment strategies.

Diagnostic accuracy of toluidine blue-stained wet films in effusion cytology

OBJECTIVE

To evaluate the usefulness of toluidine blue-stained wet films in the preliminary cytologic evaluation of serous effusions by means of specificity, sensitivity, and positive and negative predictive value.

STUDY DESIGN

One hundred seventy-six samples consisting of 122 pleural and pericardial effusions and 54 peritoneal effusions from 160 patients were included in the study. A toluidine blue-stained wet film of each sample was evaluated, and diagnoses were compared with the diagnoses by conventional smears and cell blocks on the same sample.

RESULTS

The sensitivity of wet films was 69%, 68% in pleural and pericardial effusions and peritoneal effusions, respectively, and the specificity of wet films was 93%, 92% in pleural and pericardial effusions and peritoneal effusions, respectively. Positive predictive values of smears alone were 78% and 75%; negative predictive values of smears alone were 96% and 95% in pleural and pericardial effusions and peritoneal effusions, respectively.

CONCLUSION

Preliminary cytologic evaluation of serous effusions with toluidine blue-stained wet films is simple and economical. It provides the opportunity to plan additional procedures for the samples.

The diagnosis of malignancy in effusion cytology: a pattern recognition approach

This review presents a pattern recognition approach for the diagnosis of malignant effusions. The cytomorphologic features of reactive mesothelial proliferation, mesothelioma and metastatic carcinoma are presented. In addition, the role of ancillary studies in challenging cases and the importance of integrating clinical findings are stressed. An algorithmic approach to the workup of serous effusions as well as pitfalls for false-positive diagnosis are discussed.