Subacute hemorrhagic pericardial tamponade after COVID-19 infection mimicking carcinomatous pericarditis: a case report

Abstract

Background: Coronavirus disease (COVID-19)-associated acute pericarditis has recently received much attention owing to its high frequency associated with pericardial tamponade (PT), showing unfavorable prognosis. However, early diagnosis and treatment remain challenging in cases of non-specific signs and symptoms.

Case presentation: A 64-year-old man was admitted to our hospital for acute osteomyelitis of the toes and was properly treated with antimicrobial agents. Three days after admission, the patient developed mild COVID-19 without pneumonia, for which early anti-COVID-19 agents were initiated. Nevertheless, the patient developed hemorrhagic PT due to acute pericarditis 2 weeks later, which was confirmed by cardiac magnetic resonance, requiring an urgent pericardiocentesis. Although cytological analysis of the hemorrhagic pericardial fluid strongly suggested adenocarcinoma, the atypical cells were eventually proven to be mesothelial cells with reactive atypia. Furthermore, lymph nodes swelling with abnormal 2-[18F]-fluoro-2-deoxy-D-glucose accumulation on imaging were suggestive of malignancy. However, biopsy examination revealed multiple non-caseating granulomas in the lymph node, unlikely due to malignancy. Eventually, the temporal association of the preceding COVID-19 with the occurrence of subacute PT without other identifiable cause led to a final diagnosis of COVID-19-associated acute pericarditis. With anti-inflammatory and corticosteroids treatment, the patient's symptoms involving the pericardial structure and function were completely resolved along with improvements in size of the affected lymphadenopathies.

Conclusions: We encountered a unique case of COVID-19-associated acute pericarditis exhibiting hemorrhagic PT. This case underscores the residual risk of delayed pericardial involvement even in patients with mild COVID-19 who receive early treatment, and the recognition that COVID-19 may cause various cytomorphological and histological features. Additionally, the importance of considering this rare entity as a cause of hemorrhagic pericardial effusions should be highlighted.

Keywords: COVID-19; acute pericarditis; cytology; hemorrhagic pericardial tamponade; sarcoid-like reaction.

Figure 1

Serial chest radiograph (CXR) and transthoracic echocardiography (TTE) after nosocomial infection of COVID-19. On day 3 after admission (1 day after nosocomial infection of SARS-CoV-2), CXR (A) and TTE (B, C) are unremarkable. On day 17 (15 days after nosocomial infection of SARS-CoV-2), the follow-up CXR reveals cardiac enlargement with bilateral pleural effusions (D), whereas the follow-up TTE reveals a moderate pericardial effusion with pericardial thickening (arrowheads) (E, F). Note the right ventricular collapse during early diastole (arrows). Ao, aorta; COVID-19, coronavirus disease; LA, left atrium; LV, left ventricle; PLAX, parasternal long-axis; PSAX, parasternal short-axis; RV, right ventricle; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Figure 2

The treatment effect on chest computed tomography (CT) and cardiac magnetic resonance (CMR) findings. Chest CT reveals moderate pericardial and bilateral pleural effusions with passive atelectasis (A) that resolves completely at the 6-month follow-up (D) Cine CMR reveals a moderate pericardial effusion at baseline (B) that resolves significantly at the 6-month follow-up (E) Note the entire thickening of epicardium (arrowheads) and pericardium (arrows). T2-weighted image (T2WI) shows active diffuse pericardial edema of the epicardium (arrowheads) and pericardium (arrows) observed at baseline (C) that resolves significantly at the 6-month follow-up (F). LV, left ventricle; RV, right ventricle.

Figure 3

Pericardial fluid and cytological findings and histological feature of resected lymph node. (A) Pericardial fluid shows hematogenous appearance. (B) Atypical cell nest is detected in the pericardial fluid and initially diagnosed as adenocarcinoma by Papanicolaou (PAP) staining (scale bar, 20 μm). (C) The resected lymph node shows multiple non-caseating granulomas (scale bar, 100 μm). (D) The same atypical cells observed in (B) are positive for anti-D2-40 antibody by immunocytochemistry (scale bar, 20 μm).

Figure 4

Treatment effect on lymphadenopathy on chest computed tomography (CT) imaging. Chest CT on day 18 after admission reveals right paraesophageal (white arrow) and hilar (red arrow) slight lymphadenopathies (A, B). FDG/PET-CT on day 26 reveals slight hypermetabolic activities in the same ones (C, D). Post-treatment follow-up CT on day 90 reveals a significant improvement in size of the affected lymphadenopathies (E, F). FDG/PET, positron emission tomography with 2-[18F]-fluoro-2-deoxy-D-glucose.

Figure 5

Timeline of the diagnostics, therapeutic interventions, and disease status of the present case. CEZ, cephazolin; CMR, cardiac magnetic resonance; CT, computed tomography; CXR, chest radiograph; COVID-19, coronavirus disease; Dx, diagnosis; ECG, electrocardiogram; FDG/PET, glucose analog 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography; iv, intravenous; JVD, jugular vein distention; MMSE, methicillin-sensitive Staphylococcus aureus; MRI, magnetic resonance imaging; NPS, nasopharyngeal swab; P/E, physical examination; PF, pericardial fluid; RT-PCR, reverse-transcriptase polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; SBT/ABPC, ampicillin-sulbactam; TTE, transthoracic echocardiography; VATS-biopsy, video-assisted thoracoscopic biopsy.