Massive pericardial effusion causing cardiac tamponade accompanied by elevated CA-125 and thoracic lymphadenopathy in sarcoidosis: a case report

Abstract

Introduction: Pericardial effusion and cardiac tamponade are rare manifestations of cardiac sarcoidosis. This is a first case report that describes a patient with severe pericardial effusion and signs of cardiac tamponade with elevated carbohydrate antigen 125 (CA-125) levels, enlarged pericardial (PLN) and mediastinal lymph nodes (MLN), histologically confirmed as sarcoidosis.

Presentation of case: A 51-year-old female patient was admitted with complaints of sickness, shortness of breath on minimal exertion, swelling in lower extremities, and heaviness in right upper abdomen. Patient had diminished heart sounds, peripheral edema and hepatomegaly. She had elevated CA-125 level without gynecologic pathology. There were QRS alternation on ECG and water-bottle configuration on chest-X-ray, severe pericardial effusion, and signs of cardiac tamponade on echocardiography. CT demonstrated massive pericardial effusion, pericardial mass and enlargement of anterior MLN. The patient underwent pericardial drainage with removal of 850 mL of pericardial fluid and excision of enlarged PLN. Histological examination of PLN revealed non-caseating epithelioid cell granulomas. The diagnosis of cardiac sarcoidosis was established. Patient was discharged and 6-month follow-up was uneventful.

Discussion: There are no reports on association of pericardial effusion, with increased CA-125 level in sarcoidosis, as we established in our patient. Our case is notable by incidental finding of enlarged PLN, mimicking pericardial mass and mediastinal lymphoadenopathy on CT, further confirmed by histological examination of PLN specimen as cardiac sarcoidosis.

Conclusion: It should be kept in mind that sarcoidosis may present as massive pericardial effusion, with signs of tamponade and pericardial lymphoadenopathy mimicking pericardial mass, mediastinal lymphoadenopathy and elevated CA-125, mimicking malignancy.

Keywords: CA-125; Case report; Mediastinal lymphoadenopathy; Pericardial effusion; Pericardial lymphoadenopathy; Sarcoidosis; Tamponade.

Fig. 1

Echocardiography image of a massive pericardial effusion.

Fig. 2

Computed tomography image of large pericardial effusion and pericardial mass in pericardial fat tissue (enlargement of pericardial lymph node?) (arrow).

Fig. 3

Computed tomography images of lymph nodes enlargement (arrows) in anterior mediastinum.

Fig. 4

Micropreparations of lymph nodes No. 17,133,366 (edge part). A) A- giant multi-core cells, B- healthy tissue; B) Granulomas with accumulation of epithelioid cells of macrophages on the periphery (giant multi-core cells) - A- giant multi-core cells, B- healthy tissue; C) Micropreparations of lymph nodes No. 17,133,366 (central part); Granuloma with accumulation of epithelioid cells in the center macrophages - A - focal lymphocytic infiltration. B- healthy tissue D) Pericardial micropreparations №27,133,366 of focal lymphocytic infiltration - A - focal lymphocytic infiltration. B - healthy tissue.