Pulmonary embolism with haemorrhagic pericardial effusion and tamponade: a clinical dilemma

Abstract

The synchronous presentation of a patient with pulmonary embolism (PE) and haemorrhagic cardiac tamponade is uncommon and presents a therapeutic dilemma. Both conditions can be life-threatening and require opposing management strategies. The authors report a 50-year-old woman who presented with abdominal symptoms and subsequent rapid development of dyspnoea and cardiogenic shock. Investigations demonstrated bilateral segmental PEs and a large pericardial effusion causing cardiac tamponade. This large blood-stained effusion was drained urgently. She developed acute kidney injury and acute hepatic injury with synthetic failure. She was initially deemed unsuitable for anticoagulation so an inferior vena cava filter was placed to minimise risk of further PE. When no early re-accumulation of pericardial fluid occurred, a heparin infusion was started to treat the PEs. Pericardial fluid cytology was suggestive of metastatic carcinoma, with the immunophenotype most consistent with metastatic non-small cell lung cancer. She was subsequently treated with the tyrosine kinase inhibitor, erlotinib.

Figure 1

Plain film chest radiograph (anteroposterior projection) demonstrating enlarged cardiac silhouette.

Figure 2

CT pulmonary angiogram demonstrating a large pericardial effusion (white arrow) and bilateral segmental pulmonary emboli. There is thrombus in the right upper lobe pulmonary artery and segmental branches of the lower lobe artery. There is thrombus in the left upper and lower lobe pulmonary arteries.

Figure 3

Pericardial fluid cytology with immunostaining. (A) May-Grünwald-Giemsa stain highlights the presence of a perinuclear vacuole (arrow). (B) Ber-EP4 immunoperoxidase stain confirms the epithelial nature of the cells (this indicates metastatic carcinoma rather than reactive mesothelial cells).