Friday, November 22, 2024
Subscribe American Journal of Medicine Free Newsletter
CardiologyA Silent Relic: Uremic Pericardial Effusion

A Silent Relic: Uremic Pericardial Effusion

A large pericardial effusion (red arrows) and diastolic collapse of the right ventricle, evidence of cardiac tamponade, were seen on a transthoracic echocardiogram (apical 4-chamber view)
A large pericardial effusion (red arrows) and diastolic collapse of the right ventricle, evidence of cardiac tamponade, were seen on a transthoracic echocardiogram (apical 4-chamber view)

A 52-year-old woman’s deviation from her treatment regimen put her at risk for a bygone fate. The patient presented to the hospital with gradually worsening dyspnea on exertion, nausea, vomiting, and headaches. After reporting a history of hypertension, end-stage renal disease secondary to lupus nephritis, and an inability to tolerate her oral antihypertensive medications, she was admitted with suspected hypertensive crisis. Her systemic lupus erythematosus was quiescent, and she had no recent flare-ups. She was dealing with a divorce and was in the midst of transitioning her nephrology care to a provider in another state.

Three months earlier, the patient missed multiple hemodialysis appointments, a lapse she blamed on the strain of her circumstances. Then, the following month, she stopped going altogether because she had adequate urine output and felt asymptomatic. She had no preceding viral illness or myocardial infarction and denied fevers, chills, chest pain, palpitations, or cough. Noncontrast computed tomography of the head, performed upon triage, was negative for stroke.

Assessment

On examination, the patient was afebrile, her heart rate was 81 beats per minute, respiratory rate was 18 breaths per minute, blood pressure was 221/134 mm Hg, oxygen saturation was 95% on room air, and weight was 17.6 lb (8 kg) above her established dry weight. She had no jugular venous distention. The cardiac examination showed a regular rate and rhythm with mildly diminished heart sounds and normal S1 and S2 without pericardial knock or friction rub. Her left upper-extremity arteriovenous graft had a palpable thrill and an audible bruit, and her lower extremities showed trace edema. She had no abdominal ascites, uremic frost, or skin rash.

Laboratory studies measured serum potassium at 5.5 mmol/L, blood urea nitrogen at 117 mg/dL, and creatinine at 6.54 mg/dL. The remaining results from electrolyte levels, a complete blood count, liver function tests, and coagulation studies were normal. Testing for cardiac troponins was negative. A chest radiograph showed an enlarged cardiac silhouette (Figure 1). An electrocardiogram demonstrated normal sinus rhythm, normal intervals without any PR- or ST-segment changes, and static T-wave inversions in leads V5 and V6. Electrical alternans was completely absent. A subsequent echocardiogram disclosed a large pericardial effusion with tamponade physiology and moderate reduction of ejection fraction to 35% (Figures 2 and 3).

 

To read this article in its entirety please visit our website.

-Michael A. Santos, MD, Jeremy Spinazzola, DO, Andry Van de Louw, MD, PhD

This article originally appeared in the October 2016 issue of The American Journal of Medicine.

Latest Posts

lupus

Sarcoidosis with Lupus Pernio in an Afro-Caribbean Man

A 54-year-old man of Afro-Caribbean ancestry presented with a 2-month history of nonproductive cough, 10-day history of constant subjective fevers, and a 1-day history...
Flue Vaccine

Flu Vaccination to Prevent Cardiovascular Mortality (video)

0
"Influenza can cause a significant burden on patients with coronary artery disease," write Barbetta et al in The American Journal of Medicine. For this...
varicella zoster

Varicella Zoster Virus-Induced Complete Heart Block

0
Complete heart block is usually caused by chronic myocardial ischemia and fibrosis but can also be induced by bacterial and viral infections. The varicella...
Racial justice in healthcare

Teaching Anti-Racism in the Clinical Environment

0
"Teaching Anti-Racism in the Clinical Environment: The Five-Minute Moment for Racial Justice in Healthcare" was originally published in the April 2023 issue of The...
Invisible hand of the market

The ‘Invisible Hand’ Doesn’t Work for Prescription Drugs

0
Pharmaceutical innovation has been responsible for many “miracles of modern medicine.” Reliance on the “invisible hand” of Adam Smith to allocate resources in the...
Joseph S. Alpert, MD

New Coronary Heart Disease Risk Factors

0
"New Coronary Heart Disease Risk Factors" by AJM Editor-in Chief Joseph S. Alpert, MD was originally published in the April 2023 issue of The...
Cardiovascular risk from noncardiac activities

Cardiac Risk Related to Noncardiac & Nonsurgical Activities

0
"Assessment of Cardiovascular Risk for Noncardiac and Nonsurgical Activities" was originally published in the April 2023 issue of The American Journal of Medicine. Cardiovascular risk...