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).
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-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.
