Professor of Medicine Memorial Sloan Kettering Cancer Center New York, NY, United States
Introduction: Pericardial tamponade is a life-threatening emergency caused by progressive accumulation of fluid that compresses the heart leading to hemodynamic compromise. Cancer accounts for nearly one-third of all cardiac tamponades and may also arise from chemotherapy. We describe a rare case of a hematological cancer patient who developed recurrent pericardial effusion with tamponade physiology (TP) from ascites.
Description: A 59-year-old man was diagnosed with myelodysplastic syndrome and received multiple lines of chemotherapy including methotrexate and an allogeneic hematopoietic stem cell transplant. He relapsed 7 months post-transplant and was started on chemotherapy with azacytidine, venetoclax, and enasidenib. Nine days later, he was admitted to an outside hospital for dyspnea and found to have pericardial effusion with TP and new tense ascites. He underwent a pericardiocentesis with pericardial window and paracentesis with 2L of ascites drained and discharged home. But, readmitted 3 weeks later with recurrent pericardial effusion with TP and had another pericardial window with drain placement and paracentesis with 6L removed. He was thought to have differentiation syndrome from chemotherapy and started on dexamethasone. Ten days later, he was transferred to our hospital where CT scan showed communication between a large pneumopericardium and pneumoperitoneum and echocardiogram showed bubbles within the pericardial effusion. He developed hypotension 5 days later and was transferred to the stepdown unit undergoing two more paracenteses with 7.8L drained. Cytology from the paracenteses were negative for malignancy or infection and reflected pericardial fluid cytology. A peritoneal drain was placed with resolution of pericardial effusion.
Discussion: We present an unusual case of recurrent pericardial effusion with TP caused by reflux of ascites with resolution after a peritoneal drain was placed. The recurrent ascites was related to hepatotoxicity from prior administration of methotrexate and possible that the increased abdominal pressure from the tense ascites transmitted to the pericardial space led to TP. To our knowledge, this represents the third reported case of pericardial tamponade caused by tense ascites, and the first reported case caused by a communication between both spaces.
