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Case History

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Image not available. A 49-year-old woman, established on palliative endocrine therapy for metastatic breast cancer, was admitted to hospital with shortness of breath. She had a past medical history of breast surgery, adjuvant radiotherapy and adjuvant endocrine therapy with tamoxifen. Her disease progressed with nodal, mediastinal and pulmonary metastases after three years. She had documented bony metastases affecting the sternum. On admission she was noted to be hypotensive with a sinus tachycardia and hypoxia.

What is the differential diagnosis?

What are the appropriate investigations?

How would you manage this patient?

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Background

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What is the differential diagnosis?

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Image not available. Shortness of breath can be a common feature in patients with malignancy due to the primary tumour or metastases and may be due to:

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  • thromboembolic event

  • drug-related cardiac failure

  • infection

  • development of pleural or pericardial effusion

  • anaemia.

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In this case, the patient was also haemodynamically compromised. Additional clinical signs suggesting pericardial effusion would be:

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  • raised jugular venous pressure

  • if cardiac tamponade is evident pulsus paradoxus may be present (fall in inspiratory BP >10 mmHg)

  • quiet or muffled heart sounds.

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Common causes for large pericardial effusions are neoplasia, infection (e.g. tuberculosis), uraemia and myxoedema.1 The finding of a pericardial effusion in a patient with known malignancy is commonly associated with metastatic spread.2

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Patients with a history of thoracic radiotherapy can develop a radiation-induced pericarditis with a pericardial effusion. Development of infectious or autoimmune pericardial effusions is occasionally seen in immunocompromised patients due to treatment of their malignancy.

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What are the appropriate investigations?

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The presence of a pericardial effusion may be suspected in cancer patients with any condition affecting the pericardium, including acute pericarditis. Other clues are recurrent and persistent fever, unilateral pleural effusion associated with haemodynamic compromise, or cardiomegaly on the chest X-ray. Malignancy such as breast, lung or oesophageal cancer, metastatic melanoma, lymphoma and leukemia are the most common underlying diagnosis.3-5 A full history of the duration of symptoms, along with past medical history and clinical examination (including vital signs assessing the haemodynamic impact) should be taken. Following this, an electrocardiogram (ECG), chest X-ray, and a full blood count with chemistry profile and renal function are required. Echocardiography is essential to establish the diagnosis of pericardial effusion, the haemodynamic impact of the effusion, and to check for concomitant heart disease or paracardial pathology. Cardiac tamponade, the decompensated phase of cardiac compression, develops when the intrapericardial pressure due to the increasing pericardial effusion is elevated enough to impair filling of the cardiac chambers, primarily the right ventricle. Tuberculosis, mediastinal irradiation and previous cardiac surgical procedures may lead to constrictive pericarditis with reduced preload and stroke volumes.

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A pericardial effusion appears as an echolucent space between the pericardium and the epicardium. Effusions exceeding the physiologic amount of 25-50 ml are seen ...

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