Cardiac tamponade mimicking tuberculous pericarditis as the initial presentation of chronic lymphocytic leukemia in a 58-year-old woman: a case report

Abstract

Introduction: Chronic lymphocytic leukemia is an indolent disease that often presents with complaints of lymphadenopathy or is detected as an incidental laboratory finding. It is rarely considered in the differential diagnosis of patients presenting with tamponade or a large, bloody pericardial effusion. In patients without known cancer, a large, bloody pericardial effusion raises the possibility of tuberculosis, particularly in patients from endemic areas. However, the signs, symptoms and laboratory findings of pericarditis related to chronic lymphocytic leukemia can mimic tuberculosis.

Case presentation: We report the case of a 58-year-old African American-Nigerian woman with a history of travel to Nigeria and a positive tuberculin skin test who presented with cardiac tamponade. She had a mild fever, lymphocytosis and a bloody pericardial effusion, but cultures and stains were negative for acid-fast bacteria. Assessment of blood by flow cytometry and pericardial biopsy by immunohistochemistry revealed CD5 (+) and CD20 (+) lymphocytes in both tissues, demonstrating this to be an unusual manifestation of early stage chronic lymphocytic leukemia.

Conclusion: Although most malignancies that involve the pericardium clinically manifest elsewhere before presenting with tamponade, this case illustrates the potential for early stage chronic lymphocytic leukemia to present as a large pericardial effusion with tamponade. Moreover, the presentation mimicked tuberculosis. This case also demonstrates that it is possible to treat chronic lymphocytic leukemia-related pericardial tamponade by removal of the fluid without chemotherapy.

Figure 1

A transthoracic 2-dimensional echocardiogram. Note the circumferential pericardial effusion on the long- and short-axis parasternal views on this transthoracic echocardiogram, prior to pericardiocentesis. PE, pericardial effusion; LV, left ventricle

Figure 2

A pericardial biopsy (Hematoxylin and eosin stain). Note the focal lymphocytic infiltrate in the pericardial tissue removed at the time of the subxiphoid pericardial window.

Figure 3

A pericardial biopsy (immunohistochemical stain). CD5 stain of pericardial tissue demonstrated that the vast majority of the lymphocytes were CD5 positive (brown stain).