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Case history

image 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 medical history of breast surgery, adjuvant radiotherapy and adjuvant endocrine therapy with tamoxifen. Her disease progressed with nodal, mediastinal and pulmonary metastases after 3 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 should this patient be managed?

What is the differential diagnosis?

Shortness of breath is a common feature in patients with malignancy due to the primary tumour or metastases. It may also be due to:

  • thromboembolic event;

  • drug-related cardiac failure;

  • infection;

  • development of pleural or pericardial effusion;

  • anaemia.

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

  • raised jugular venous pressure;

  • if cardiac tamponade is evident, presence of pulsus paradoxus (fall in inspiratory blood pressure >10 mmHg);

  • quiet or muffled heart sounds.

In most developed nations, the leading cause of pericardial effusion is idiopathic (50%); other common causes include infection (15–30%), iatrogenic (15–20%), connective tissue disease (5–15%) and cancer (15–20%).1 In the developing world, tuberculosis is the most common cause of pericardial effusion (>60%).2 Development of malignant pericardial effusion (MPE) is associated with poor prognosis and has been found to be the leading cause of cardiac tamponade in many tertiary care hospitals.3,4

The finding of pericardial effusion in a patient with known malignancy is commonly associated with metastatic spread but may also occur secondary to inflammation, infection, heart failure or complications of treatment.5 Patients with a history of thoracic radiotherapy may develop 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.

What are the appropriate investigations?

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 chest X-ray. Malignancies such as breast, lung or oesophageal cancer, metastatic melanoma, lymphoma and leukaemia are the most common underlying diagnosis.4,6,7 A full history of the duration of symptoms, along with the medical history and a clinical examination (including vital signs assessing the haemodynamic status) should be taken, after which an ECG, chest X-ray and full blood count with chemistry profile and renal function are required. Echocardiography is essential to establish the diagnosis and haemodynamic impact of the pericardial effusion and to check for concomitant heart disease or pericardial pathology. Echocardiography remains the key investigation; however, increasing use of CT and cardiac MR imaging ...

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