Evaluation of Pericardial Effusions in Alopecia Patients on Low-Dose Oral Minoxidil Therapy.

BACKGROUND: Minoxidil is an anti-hypertensive vasodilator increasingly used off-label for the treatment of alopecia. It is associated with an increased risk of pericardial effusions, with recent reports even in patients on low-dose oral minoxidil (LDOM) therapy. OBJECTIVE: To evaluate whether LDOM is associated with increased prevalence of pericardial effusions in patients with alopecia. METHODS: In this cross-sectional study, point-of-care ultrasound was used to screen alopecia patients at dermatology appointments. Scans were evaluated by two independent cardiologists for the presence and size of effusions. The prevalence of effusions was compared between patients on LDOM therapy and patients not on minoxidil therapy. RESULTS: A total of 100 patients were evaluated for pericardial effusion: 51 LDOM patients and 49 control patients. The two groups were similar in terms of age (53.7 vs 54.1; P=0.91), sex (86% vs 73% female; P=0.14), and race. Small pericardial effusions (<1 cm) were identified in 5.8% of LDOM patients and 6% of control patients (P=1), none of which were symptomatic. LIMITATIONS: This is a small, cross-sectional study with limitations on speculation of causality in confirmed cases. CONCLUSION: We did not find evidence of increased prevalence of pericardial effusions in a small group of alopecia patients on LDOM. J Drugs Dermatol. 2024;23(9):725-728. doi:10.36849/JDD.8029.

Central lung adenocarcinoma in a young male mimicking pneumonia with nonrecurrent polyserous effusions of negative cytology: A case report.

INTRODUCTION AND IMPORTANCE: Lung adenocarcinoma may resemble the clinical presentation of an infectious or inflammatory lung disease. The coexistence of lung cancer, and polyserous effusions is uncommon, which may cause a diagnostic challenge. However, any polyserous effusions at a young age must always be suspicious for malignancy. CASE PRESENTATION: We report a case of 38-year-old male patient with polyserous effusions and pneumonia who was treated accordingly and showed clinical improvement with a significant reduction of pericardial and pleural effusions. Subsequent testing and a biopsy resulted in the histopathological diagnosis of an adenocarcinoma of the lung. CLINICAL DISCUSSION: Nonrecurrent polyserous effusions in lung adenocarcinoma are uncommon, and negative cytology results may not exclude malignancy due to the moderate sensitivity of pleural and pericardial fluid cytology. Clinicians should remain vigilant for false-negative results, especially in younger patients. Malignancy should not be ruled out because pleural and pericardial fluid cytology have a sensitivity of 60% and 92%, respectively. CONCLUSION: Our case highlights the diagnostic challenges posed by atypical presentations of lung adenocarcinoma and emphasizes the importance of considering malignancy in the differential diagnosis of polyserous effusions, even when initial cytology results are negative. Clarifying the rationale for this study enhances its relevance and impact.

A case of t-cell lymphoblastic lymphoma characterized by pleural effusion combined with pericardial effusion.

This case underscores the pivotal role of early cytological examination of bodily fluids in the preliminary detection of lymphoma, a conclusion reinforced by subsequent pathological findings and refined through immunohistochemical characterization. A morphological analysis of pleural effusion cells was conducted in a 25-year-old male presenting initially with concurrent pleural and pericardial effusions. Initial morphological assessment of effusion specimens indicated the likelihood of a lymphoproliferative disorder. Subsequent detailed pathological and immunohistochemical investigations confirmed this suspicion, culminating in a definitive diagnosis of T-cell lymphoblastic lymphoma (T-LBL). The case emphasizes the necessity of employing a comprehensive and synergistic diagnostic approach, facilitating prompt and accurate diagnosis and subtyping of lymphoma.

A Rare Case of Effusive Pericarditis: Overlap Syndrome.

Systemic autoimmune disease contributes up to ~22% of cases of pericarditis with known etiology. Systemic lupus erythematosus (SLE) is a multisystem disease with a variety of clinical presentations and manifestations. Since the underlying mechanism for pericardial involvement differs with each systemic disease, this leads to poor understanding of its management. However, it is rare for acute pericarditis to be the leading symptom at the time of diagnosis of SLE, occurring in up to 1% of patients. This is a case report of a 21-year-old female who presented with breathlessness and pedal edema, who was previously misdiagnosed with tubercular pericarditis and was started on antitubercular treatment (ATT). Now she is diagnosed with autoimmune pericarditis with SLEoverlap syndrome. Pericarditis, being the most common cardiac manifestation of SLE, has an incidence ranging between 11 and 54%. Knowledge of such association is necessary to avoid misdiagnosis.

Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome.

Camptodactyly-arthropathy-coxa vara-pericarditis syndrome (CACP) is a rare autosomal recessive disease caused by mutation in proteoglycan 4 (PRG4) gene on chromosome 1q25-q31. We faced a dilemma and delay in diagnosis in two sisters. The elder sister had pericardial effusion with constrictive pericarditis, underwent pericardiectomy and received empirical treatment for suspected tuberculosis. After 2 years, she developed bilateral knee swelling with restriction of movement. At the same time, her younger sister also presented with bilateral knee swelling which aroused the suspicion of genetic disease. The whole-genome sequencing revealed homozygous PRG4 mutation suggestive of CACP syndrome.

Apixaban-Induced Hemopericardium in a Post-TAVR Patient: A Case Report Highlighting Diagnostic and Management Challenges.

BACKGROUND Despite having many benefits, frequently-used medications may still have potential risks and can cause harm. Hemopericardium is a lethal pathology with a high risk of mortality and a lower differential diagnosis consideration. When adding both mentioned elements, their consideration as a differential diagnosis would require a higher threshold. This report presents a 66-year-old man with atrial fibrillation, heart failure, and aortic stenosis status post transcatheter aortic valve replacement (TAVR) 1 year ago with hemopericardium while treated with apixaban. CASE REPORT We present the case of a 66-year-old man with multiple medical conditions, including atrial fibrillation, heart failure, and aortic stenosis post-transcatheter aortic valve replacement 1 year before admission, who presented with 2 weeks of dyspnea and lower-limb swelling. Initial assessments revealed atrial fibrillation, elevated brain natriuretic peptide, and a chest X-ray indicating possible left pleural effusion and cardiomegaly. On day 4, an echocardiogram identified a large hemopericardium and tamponade, prompting urgent surgery. A pericardial window was performed, draining 1700 cc of bloody fluid. The postoperative improvement included normalized hemodynamics and echocardiographic findings. Pathology confirmed hemopericardium. The follow-up echocardiogram showed improved cardiac function, and the patient was transferred to the general medical floor. CONCLUSIONS This case sheds light on the uncommon but critical complications associated with direct oral anticoagulant therapy. With only a handful of reported cases, the rarity of this condition underscores the need for heightened awareness among clinicians. The patient's intricate medical history accentuates the challenges in managing anticoagulation in individuals with multiple comorbidities.

Severe myxedema coma and pericardial effusion in a child with Down syndrome: the importance of adherence to levothyroxine therapy.

BACKGROUND: Myxedema coma is a rare, but life-threatening endocrinological emergency. Myxedema is characterized by altered mental status, and is accompanied by hypotension, bradycardia, hypothermia, bradypnea, hyporeflexia, hyponatremia, and hypoglycemia, all stemming from reduced metabolism due to severe hypothyroidism. Additionally, patients may exhibit signs of low cardiac output, edema in the extremities, peripheral circulatory disturbances, shock, and the development of pericardial and pleural effusions, ultimately leading to confusion and coma. We present a successfully treated case of severe myxedema coma with recurrent pericardial effusion and hypotensive shock. This case is characterized by an unusual clinical presentation and required a distinct treatment strategy highlighting its exceptional rarity. CASE: A 2-year-old boy with Down syndrome presented with recurrent pericardial effusion attributed to medication non-adherence. The critically-ill patient, experiencing a severe cardiogenic shock required mechanical ventilation and inotropic infusions in the pediatric intensive care unit. Elevated thyroid stimulating hormone (TSH), and low free T4 (fT4) and free T3 (fT3) levels prompted consideration of myxedema coma. Upon reviewing the patient's medical history, it was ascertained that he had an ongoing diagnosis of primary hypothyroidism, and exhibited non-adherence to the prescribed treatment regimen and failed to attend scheduled outpatient clinic appointments for follow-up assessments. The treatment plan, devised by the pediatric endocrinology team, included the peroral administration of L-thyroxine (L-T4) at a dose of 50 micrograms per day. After beginning regular oral L-T4 treatment, a gradual improvement in the patient's condition was observed. Notably, by the 15th day of oral therapy, the patient had made a full recovery. Contrary to the recommended intravenous treatment for myxedema coma, this patient was successfully treated with oral levothyroxine, due to the unavailability of the parenteral form in Türkiye. CONCLUSIONS: This case report presents an instance of non-adherence to L-T4 therapy, which subsequently progressed to severe myxedema coma. Changes in neurologic status and hemodynamic instability in a patient with a history of hypothyroidism should raise the concern of nonadherence and, though rare, myxedema coma should be in the differential diagnosis.

Pericardial Effusion as a Complication of Severe Primary Hypothyroidism.

Large pericardial effusions with associated cardiac tamponade are a rare manifestation of hypothyroidism. We present the case of a 63-year-old female with chronic heart failure and newly diagnosed hypothyroidism, who presented to her primary care physician complaining of progressively worsening dyspnea. Chest radiography showed cardiomegaly and transthoracic echocardiography (TTE) revealed a large pericardial effusion with tamponade physiology. An emergent pericardial window was performed, resulting in an improvement in left ventricular systolic function. Pericardial tissue biopsy was normal. Thyroid function tests were consistent with severe primary hypothyroidism. After inpatient treatment with intravenous levothyroxine and interval resolution of symptoms without recurrence of effusion, the patient was discharged home on oral levothyroxine therapy. Close follow up with surveillance echocardiography was planned. While metabolic disorders are seldom thought of as an etiology, it is imperative for clinicians to recognize hypothyroidism as a cause of the pericardial effusion. It is one of the few reversible causes and delay in treatment can result in fatal sequelae.

Successful Visceral and Parietal Pericardiectomy for Refractory Effusive-Constrictive Pericarditis: A Challenging Case Report.

BACKGROUND Effusive-constrictive pericarditis (ECP) is an uncommon clinical syndrome characterized by the coexistence of pericardial effusion and constriction involving the visceral pericardium. This differs from constrictive pericarditis, which presents with thickening of the pericardium without effusions. Specific diagnostic criteria of ECP include the failure of right atrial pressure to decrease by 50% or reach a new level below 10 mmHg after normalization of intrapericardial pressure. CASE REPORT We present the case of a 32-year-old obese man with multiple comorbidities who initially presented with flu-like symptoms and pleural effusion with development of constrictive-like symptoms. Despite undergoing numerous pericardiocentesis and appropriate medical management, the patient's condition failed to improve, leading to the likely diagnosis of effusive-constrictive pericarditis. Cultures of pericardial fluid revealed E. -faecium, which required multiple antimicrobial therapy. Despite infection, the exact etiology of ECP remained unknown and likely idiopathic. Common causes of ECP include idiopathic, tuberculosis, cardiac surgery complications, radiation, or neoplasia. Ultimately, the patient underwent a pericardiectomy involving the visceral and parietal pericardium, resulting in hemodynamic stability and resolution of symptoms. CONCLUSIONS This case highlights the challenges in diagnosing and managing ECP, emphasizing the importance of considering surgical intervention in refractory cases. ECP initially presents as a pericardial effusion, often addressed through pericardiocentesis; however, in a small subset of patients, sustained symptoms and altered hemodynamics persist following pericardiocentesis, necessitating further evaluation and management. The success of pericardiectomy in our patient highlights the potential efficacy of surgical intervention in improving outcomes for patients with ECP.

Acute Pericarditis: Rapid Evidence Review.

Acute pericarditis is defined as inflammation of the pericardium and occurs in approximately 4.4% of patients who present to the emergency department for nonischemic chest pain, with a higher prevalence in men. Although there are numerous etiologies of pericarditis, most episodes are idiopathic and the cause is presumed to be viral. Diagnosis of pericarditis requires at least two of the following criteria: new or worsening pericardial effusion, characteristic pleuritic chest pain, pericardial friction rub, or electrocardiographic changes, including new, widespread ST elevations or PR depressions. Pericardial friction rubs are highly specific but transient, and they have been reported in 18% to 84% of patients with acute pericarditis. Classic electrocardiographic findings include PR-segment depressions; diffuse, concave, upward ST-segment elevations without reciprocal changes; and T-wave inversions. Transthoracic echocardiography should be performed in all patients with acute pericarditis to characterize the size of effusions and evaluate for complications. Nonsteroidal anti-inflammatory drugs are the first-line treatment option. Glucocorticoids should be reserved for patients with contraindications to first-line therapy and those who are pregnant beyond 20 weeks' gestation or have other systemic inflammatory conditions. Colchicine should be used in combination with first- or second-line treatments to reduce the risk of recurrence. Patients with a higher risk of complications should be admitted to the hospital for further workup and treatment.

Massive pericardial effusion in an infant with Aymé-Gripp syndrome: A case report and review of the literature.

Aymé-Gripp syndrome (AYGRPS) is a multisystemic disorder caused by a subset of pathogenic variants in the MAF gene. Major clinical features include bilateral early cataracts, sensorineural hearing loss (SNHL), and a characteristic facial appearance along with variable neurodevelopmental delay. Pericarditis resulting in pericardial effusion of varying degree has been observed in a subset of affected individuals and could represent a severe feature in neonatal or infantile age. Here, we describe a syndromic infant with massive pericardial effusion and craniofacial features that oriented toward the suspicion of AYGRPS, which was subsequently confirmed by the molecular analysis of MAF. Pericardial effusion was first observed prenatally and documented to be recurrent, progressive, and severe in the first months of life, thus requiring pericardiocentesis and surgical procedures. In this report, we provide further delineation of the minor clinical characteristics, particularly focusing on cardiac features of AYGRPS. A dedicated cardiac surveillance of these findings may help reduce the morbidity and mortality of this rare condition.

Pericardial Disease in Cardiac Amyloidosis: A Comprehensive Review.

In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.

Cardiac Tamponade and Pericardiocentesis: Recognition, Standard Techniques, and Modern Advancements.

Pericardiocentesis is an important diagnostic and therapeutic procedure. In the setting of cardiac tamponade, pericardiocentesis can rapidly improve hemodynamics, and in cases of diagnostic uncertainty, pericardiocentesis allows for fluid analysis to aid in diagnosis. In contemporary practice, the widespread availability of ultrasonography has made echocardiographic guidance the standard of care. Additional tools such as micropuncture technique, live ultrasonographic guidance, and adjunctive tools including fluoroscopy continue to advance and enhance procedural efficiency and safety. When performed by experienced operators, pericardiocentesis is a safe, effective, and potentially life-saving procedure.

Pericardial Effusion in Association With Periodontitis: Case Report and Review of 8 Patients in Literature.

Periodontal diseases are well-known background for infective endocarditis. Here, we show that pericardial effusion or pericarditis might have origin also in periodontal diseases. An 86-year-old man with well-controlled hypertension and diabetes mellitus developed asymptomatic increase in pericardial effusion. Two weeks previously, he took oral new quinolone antibiotics for a week because he had painful periodontitis along a dental bridge in the mandibular teeth on the right side and presented cheek swelling. The sputum was positive for Streptococcus species. He was healthy and had a small volume of pericardial effusion for the previous 5 years after drug-eluting coronary stents were inserted at the left anterior descending branch 10 years previously. The differential diagnoses listed for pericardial effusion were infection including tuberculosis, autoimmune diseases, and metastatic malignancy. Thoracic to pelvic computed tomographic scan demonstrated no mass lesions, except for pericardial effusion and a small volume of pleural effusion on the left side. Fluorodeoxyglucose positron emission tomography disclosed many spotty uptakes in the pericardial effusion. The patient denied pericardiocentesis, based on his evaluation of the risk of the procedure. He was thus discharged in several days and followed at outpatient clinic. He underwent dental treatment and pericardial effusion resolved completely in a month. He was healthy in 6 years until the last follow-up at the age of 92 years. We also reviewed 8 patients with pericarditis in association with periodontal diseases in the literature to reveal that periodontal diseases would be the background for developing infective pericarditis and also mediastinitis on some occasions.

From the archives of MD Anderson Cancer Center. Mesothelial/monocytic incidental cardiac excrescence with a review of the literature.

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a rare benign lesion composed of monocytes and mesothelial cells that is most often encountered during cardiothoracic surgery. We describe a case in a 71-year-old man with known aortic valve stenosis who presented with gradual onset dyspnea over a few weeks, made worse with minimal exertion. A transesophageal echocardiogram revealed severe aortic stenosis and mild pericardial effusion. The patient underwent aortic valve replacement, coronary artery bypass, and amputation of the left atrial appendage. Histological examination of a 0.8 cm blood clot received along with the atrial appendage showed an aggregation of bland cells with features of monocytes associated with small strands and nodules of mesothelial cells, fat cells, fibrin and a minute fragment of bone. Immunohistochemical analysis showed that the monocytic cells were positive for CD4 and CD68 (strong) and negative for calretinin and keratin. By contrast, the mesothelial cells were positive for calretinin and keratin and negative for all other markers. In sum, the morphologic and immunohistochemical findings support the diagnosis of MICE. Based on our review of the literature, about 60 cases of MICE have been reported previously which we have tabulated. We also discuss the differential diagnosis.

Cardiac evaluation in pregnant patients with dyspnea and palpitations.

BACKGROUND: Symptoms of underlying cardiac disease in pregnancy can often be mistaken for common complaints because of normal physiological changes in pregnancy. Echocardiographic evaluation of patients with symptoms of palpitations and dyspnea can detect structural changes and identify high-risk features. OBJECTIVE: This study aimed to examine transthoracic echocardiograms of perinatal individuals completed for palpitations or dyspnea to determine the frequency of identifying structural changes. STUDY DESIGN: This was a retrospective cohort study of all perinatal individuals with a transthoracic echocardiogram at a single academic center between October 1, 2017, and May 1, 2022. The indication for the echocardiogram, demographics, and clinical characteristics were recorded. Transthoracic echocardiograms with any abnormal findings noted in the transthoracic echocardiogram report were reviewed and categorized into findings of congenital heart disease, valvular disease, pericardial effusion, evidence of ischemia or wall motion abnormalities, abnormal diastolic or systolic function, and other. RESULTS: Of 539 transthoracic echocardiograms completed on 478 individuals who were pregnant or in the 12-week postpartum period, 96 (17.8%) had an indication of palpitations, and 32 (5.9%) had an indication of dyspnea. Abnormal findings were seen in 21.9% of patients with palpitations and in 34.4% of patients with dyspnea. In patients with palpitations who had abnormal findings, 33.3% had congenital heart disease; 33.3% had mild valvular disease, including mitral valve prolapse; 19.0% had a pericardial effusion; and 14.3% had evidence of ischemia or wall motion defects. Abnormal transthoracic echocardiogram findings in the dyspnea cohort included ischemia or wall motion defects (27.3%), mild valvular disease or mitral valve prolapse (36.4%), and abnormal systolic or diastolic function (36.4%). CONCLUSION: Many of the transthoracic echocardiograms completed for patients with dyspnea or palpitations identified no structural abnormality; however, in 1 of 3 to 1 of 4 patients, underlying structural heart disease was identified. Although some of these abnormalities were unlikely to change delivery plans, such as mild valvular disease or small effusions, other abnormalities, such as ischemia, congenital abnormalities, and abnormal systolic or diastolic function, were likely to have implications for pregnancy and postpartum management.

Initial diagnosis of extranodal NK/T-cell lymphoma in pericardial fluid with concomitant hemophagocytic lymphohistiocytosis (HLH).

Extranasal natural killer/T-cell lymphoma arising in the heart is rare and typically presents with non-specific clinical symptoms, necessitating a biopsy for a definitive diagnosis. We report an unusual case of a 48-year-old male who initially presented with chest pain and shortness of breath. Subsequent diagnosis via pericardial fluid analysis, including flow cytometry and immunohistochemical stains, revealed extranasal NK/T-cell lymphoma without sinonasal involvement. The analysis identified neoplastic lymphoid cells expressing CD2, cytoplasmic CD3, Epstein-Barr virus, and CD56 and exhibiting increased Ki-67 staining. Additionally, the patient developed hemophagocytosis lymphocytosis secondary to NK/T cell lymphoma. Treatment included an interleukin-1 receptor antagonist (anakinra), dexamethasone, rituximab, and etoposide. Unfortunately, the patient's condition rapidly deteriorated, leading to multiorgan failure and eventual demise. Given the rarity of this lymphoma, early diagnosis based on a high suspicion level provides the best chance for improved overall survival.

Cardiac Tuberculosis: A Case Series from Ethiopia, Italy, and Uganda and a Literature Review.

Extrapulmonary tuberculosis (TB) is estimated to account for up to 20% of active cases of TB disease, but its prevalence is difficult to ascertain because of the difficulty of diagnosis. Involvement of the heart is uncommon, with constrictive pericarditis being the most common cardiac manifestation. Diagnostic research for cardiac disease is frequently lacking, resulting in a high mortality rate. In addition to direct cardiac involvement, instances of cardiac events during antitubercular therapy are described. This case series describes five cases of TB affecting the heart (cardiac TB) from Italy and high-burden, low-income countries (Ethiopia and Uganda), including a case of Loeffler syndrome manifesting as myocarditis in a patient receiving antitubercular therapy. Our study emphasizes how cardiac TB, rare but important in high-burden areas, is a leading cause of pericardial effusion or pericarditis. Timely diagnosis and a comprehensive approach, including imaging and microbiological tools, are crucial. Implementing high-sensitivity methods and investigating alternative samples, such as detection of tuberculosis lipoarabinomannan or use of the GeneXpert assay with stool, is recommended in TB control programs.