Cáncer de mama metastásico y embarazo: reporte de caso / Metastatic breast cancer and pregnancy: a case report

Resumen ANTECEDENTES: El cáncer de mama es la segunda neoplasia maligna más común asociada con el embarazo. Su tratamiento es complejo debido a los riesgos en el feto en el contexto del tratamiento de la madre. CASO CLÍNICO: Paciente de 28 años, enviada del Hospital Naval de Chetumal, Quintana Roo, con 13.1 semanas de embarazo por fecha de la última menstruación. En la tomografía computada se advirtió la existencia de un derrame pleural del 70%, otro pericárdico y sospecha de metástasis osteoblástica a la columna torácica. En la exploración física se encontró con dinámica ventilatoria, amplexión y amplexación disminuida derecha, hipoventilación interescapular y basal derecha, con disminución a la trasmisión de voz, submatidez basal derecha y, hacia el lado izquierdo, un murmullo vesicular. Los estudios citoquímico y citológico de líquido pericárdico y pleural se reportaron positivos para malignidad. En la resonancia magnética de la columna se encontraron lesiones sugerentes de actividad tumoral en los cuerpos vertebrales T12 a L5. Debido al avanzado estado metastásico del cáncer se propuso la interrupción del embarazo con el propósito de no retrasar el tratamiento. El perfil biológico reportó: inmunofenotipo triple negativo (receptores de estrógeno y progesterona: negativo, HER2: negativo en células neoplásicas). Se le indicó tratamiento con quimioterapia sistémica (carboplatino-paclitaxel). CONCLUSIÓN: El diagnóstico de cáncer de mama durante el embarazo dificulta la detección e interpretación de las anormalidades mamarias, retrasa el diagnóstico, permite el crecimiento del tumor y se incrementa el riesgo metastásico de la enfermedad. El tratamiento oncológico adecuado y su valoración multidisciplinaria son decisivos para favorecer la supervivencia.

Abstract BACKGROUND: Breast cancer is the second most common malignancy associated with pregnancy. Its treatment is complex due to fetal risks in the context of treatment of the mother. CLINICAL CASE: 28-year-old patient, referred from the Naval Hospital of Chetumal, Quintana Roo, with 13.1 weeks of pregnancy by date of last menstrual period. The CT scan showed a 70% pleural effusion, another pericardial effusion and suspicion of osteoblastic metastasis to the thoracic spine. Physical examination showed ventilatory dynamics, decreased right amplexion and amplexation, interscapular and right basal hypoventilation, with decreased voice transmission, right basal submatitis and, to the left side, a vesicular murmur. Cytochemical and cytological studies of pericardial and pleural fluid were positive for malignancy. MRI of the spine showed lesions suggestive of tumor activity in the vertebral bodies T12 to L5. Due to the advanced metastatic stage of the cancer, termination of pregnancy was proposed in order not to delay treatment. The biological profile reported: triple negative immunophenotype (estrogen and progesterone receptors: negative, HER2: negative in neoplastic cells). Treatment with systemic chemotherapy (carboplatin-paclitaxel) was indicated. CONCLUSION: The diagnosis of breast cancer during pregnancy hinders the detection and interpretation of breast abnormalities, delays diagnosis, allows tumor growth and increases the metastatic risk of the disease. Adequate oncologic treatment and its multidisciplinary assessment are decisive in favoring survival.

Janelas Pericárdicas: O Valor Limitado do Diagnóstico da Biópsia Pericárdica não Guiada / Pericardial Windows: The Limited Diagnostic Value of Non-Targeted Pericardial Biopsy

Resumo Fundamento A janela pericárdica, além de promover a drenagem pericárdica, também pode fornecer amostras do pericárdio para exame anatomopatológico. No entanto, a contribuição dessas biópsias para a elucidação da etiologia do derrame pericárdico tem sido debatida. Objetivo Analisar o valor diagnóstico da biópsia pericárdica não guiada obtida de procedimentos de janela pericárdica. Métodos Foram revisados retrospectivamente dados de 80 pacientes submetidos a biópsia pericárdica parietal de 2011 a 2020. A significância estatística foi considerada quando p < 0,05. Resultados Cinquenta pacientes eram do sexo masculino (62,5%) e 30 do sexo feminino (37,5%). A mediana de idade foi de 52 anos (intervalo interquartil: 29 a 59) e 49 anos (intervalo interquartil: 38 a 65), respectivamente (p = 0,724). A etiologia suspeita do derrame pericárdico foi neoplásica em 31,3%, incerta em 25%, tuberculose em 15%, autoimune em 12,5%, síndrome edemigênica em 7,5% e outras condições diversas em 8,8%. A abordagem mais frequente para drenagem pericárdica e biópsia foi a subxifoide (74%), seguida pela videotoracoscopia (22%). Em 78,8% das biópsias, os achados histopatológicos foram compatíveis com inflamação inespecífica, e apenas 13,7% de todas as biópsias produziram um diagnóstico histopatológico conclusivo. Aqueles que sofriam de câncer e derrame pericárdico apresentaram maior proporção de achados histopatológicos conclusivos (32% apresentavam infiltração neoplásica pericárdica). A taxa de mortalidade hospitalar foi de 27,5% e 54,5% dos pacientes que morreram no hospital tinham câncer. Nenhuma morte foi atribuída ao tamponamento cardíaco ou ao procedimento de drenagem. Conclusão Nossos resultados mostraram que a janela pericárdica é um procedimento seguro, mas teve pouco valor para esclarecer a etiologia do derrame pericárdico e nenhum impacto na terapia planejada para o diagnóstico primário além da descompressão cardíaca.

Abstract Background Pericardial window, in addition to promoting pericardial drainage, can also provide samples of the pericardium for anatomopathological examination. However, such biopsies' contribution to clarifying the etiology of pericardial effusion has been debated. Objective To analyze the diagnostic value of non-targeted pericardial biopsy obtained from pericardial window procedures. Methods Data from 80 patients who had undergone parietal pericardial biopsies from 2011 to 2020 were retrospectively reviewed. Statistical significance was considered if p < 0.05. Results Fifty patients were male (62.5%,) and 30 were female (37.5%). The median age was 52 years (interquartile range: 29 to 59) and 49 years (interquartile range: 38 to 65), respectively (p = 0.724). The suspected etiology of pericardial effusion was neoplastic in 31.3%, unclear in 25%, tuberculosis in 15%, autoimmune in 12.5%, edemagenic syndrome in 7.5%, and other miscellaneous conditions in 8.8%. The most frequent approach for pericardial drainage and biopsy was subxiphoid (74%), followed by video-assisted thoracoscopy (22%). Overall, in 78.8% of the biopsies, the histopathologic findings were compatible with nonspecific inflammation, and only 13.7% of all biopsies yielded a conclusive histopathological diagnostic. Those suffering from cancer and pericardial effusion had a higher proportion of conclusive histopathologic findings (32% had pericardial neoplastic infiltration). The hospital mortality rate was 27.5%, and 54.5% of the patients who died in the hospital had cancer. No deaths were attributed to cardiac tamponade or the drainage procedure. Conclusion Our results showed that pericardial window is a safe procedure, but it had little value to clarify the pericardial effusion etiology and no impact on the planned therapy for the primary diagnosis besides the cardiac decompression.

Manejo conservador del hemopericardio por trauma: reporte de un caso / Conservative management of traumatic hemopericardium: Case report

Introducción. El trauma cardíaco penetrante es una patología con alta mortalidad, que alcanza hasta el 94 % en el ámbito prehospitalario y el 58 % en el intrahospitalario. El algoritmo internacional para los pacientes que ingresan con herida precordial, hemodinámicamente estables, es la realización de un FAST subxifoideo o una ventana pericárdica, según la disponibilidad del centro, y de ser positivo se procede con una toracotomía o esternotomía. Métodos. Se hizo una búsqueda bibliográfica en las bases de datos Medline, Pubmed, Science Direct y UpTodate, usando las palabras claves: "taponamiento cardíaco", "herida precordial" y "manejo no operatorio". Se tomaron los datos de la historia clínica y las imágenes, previa autorización del paciente. Caso clínico. Paciente masculino ingresó con herida en área precordial, estable hemodinámicamente, sin signos de sangrado activo, con FAST subxifoidea "dudosa". Se procedió a realizar ventana pericárdica, la cual fue positiva para hemopericardio de 150 ml; se evacuaron los coágulos del saco pericárdico, se introdujo sonda Nelaton 10 Fr para lavado con solución salina 500 ml, hasta obtener retorno de líquido claro. Frente al cese del sangrado y estabilidad del paciente se decidió optar por un manejo conservador, sin toracotomía. Conclusiones. No todos los casos de hemopericardio traumático por herida por arma cortopunzante requieren toracotomía. El manejo conservador con ventana pericárdica, drenaje de hemopericardio más lavado y dren es una opción en aquellos pacientes que se encuentran estables hemodinámicamente y no se evidencia sangrado activo posterior al drenaje del hemopericardio.

Introduction. Penetrating cardiac trauma is a pathology with high mortality, reaching up to 94% in the prehospital and 58% in the hospital settings. The international algorithm for patients who are admitted to the hospital with a precordial wound and who are hemodynamically stable is to perform a subxiphoid FAST echo or a pericardial window according to the availability of the center and, if positive, proceed to perform thoracotomy or sternotomy. Methods. A literature search was made in the Medline, Pubmed, ScienceDirect, and UpTodate biomedical databases, using the keywords "cardiac tamponade", "precordial wound" and "non-operative management". The data was taken from the clinical history, the images and the surgical procedure. Clinical case. Male patient who was admitted to the emergency room due to a wound in the precordial area, hemodynamically stable without signs of active bleeding, with subxiphoid FAST that is reported as "doubtful". We proceeded to perform a pericardial window which is positive for 150 ml hemopericardium, evacuation of clots from the pericardial sac, inserted a 10 Fr Nelaton catheter and washed with 500 ml saline solution until the return of clear fluid was obtained. In view of the cessation of bleeding and the stability of the patient, it was decided to opt for a conservative management and not to perform a thoracotomy. Conclusions. Not all cases of traumatic hemopericardium from a sharp injury require thoracotomy. Conservative management with pericardial window drainage of the hemopericardium plus lavage and drain is an option in those patients who are hemodynamically stable and there is no evidence of active bleeding after drainage of the hemopericardium.

Descripción de un caso de hernia diafragmática de Morgagni con derrame pericárdico masivo resuelto mediante pericardiocentesis intrauterina / Description of a case of Morgagni's diaphragmatic hernia with massive pericardial effusion resolved by intrauterine pericardiocentesis

Introducción: Las hernias diafragmáticas de Morgagni diagnosticadas prenatalmente son una rara entidad, con menor riesgo asociado de hipoplasia pulmonar y problemas respiratorios que las hernias diafragmáticas posteriores. Nuestro caso pone de manifiesto cómo en los casos de hernia diafragmática de Morgagni los pulmones tienden a desarrollarse completamente, a pesar del significativo derrame pericárdico o cuán disminuidos pueden aparentar. Principales síntomas y/o hallazgos clínicos: Hernia diafragmática de Morgagni diagnosticada a las 14 semanas de gestación, con derrame pericárdico masivo y herniación torácica anterior del hígado. Diagnósticos principales, intervenciones terapéuticas y resultados: No se identificaron otras malformaciones asociadas, se descartaron otras causas de derrame pericárdico y el cariotipo fetal analizado fue normal. A las 25 semanas, se realizó una pericardiocentesis fetal intrauterina, consiguiendo una significativa distensión pulmonar, con una adecuada vascularización. Tras el nacimiento, la recién nacida precisó soporte ventilatorio debido a una hipoxemia severa causada por la hipertensión pulmonar, corrigiéndose el defecto quirúrgicamente a los 6 días de vida. La evolución posterior fue favorable, sin presentar problemas respiratorios significativos. Conclusión: La detección ecográfica de esta rara anomalía resulta útil para el manejo óptimo, y el drenaje pericárdico puede favorecer una resolución prenatal del derrame pericárdico, permitiéndonos evaluar de forma adecuada el riesgo de hipoplasia pulmonar.(AU)

Introduction: Morgagni diaphragmatic hernia with prenatal diagnosis is a rare entity, with lower risk of pulmonary hypoplasia and respiratory problems than posterior diaphragmatic hernia. Our case highlights how in Morgagni diaphragmatic hernia cases lungs tend to develop properly, despite significant pericardial effusion or how greatly diminished they may seem. Main symptoms and/or clinical findings: Morgagni diaphragmatic hernia diagnosed at 14 weeks, with massive pericardial effusion and anterior thoracic herniation of the liver. Main diagnosis, therapeutic interventions, and results: No other malformations were identified, other causes of pericardial effusion were ruled out and foetal karyotype was normal. At 25 weeks, in-utero pericardiocentesis was performed, observing significant pulmonary distension and adequate vascularization. After delivery, the newborn required respiratory support due to severe hypoxaemia related to pulmonary hypertension. Six days later surgical diaphragm closure was performed. The newborn had no significant respiratory problems and progressed positively after surgery. Conclusion: Ultrasonographic detection of this rare anomaly is useful for optimal management, and pericardial drainage can provide prenatal resolution of pericardial effusion, enabling us to evaluate pulmonary hypoplasia risk.(AU)

Isolated fetal pericardial effusion follow-up: Should we worry?

INTRODUCTION AND OBJECTIVES: Fetal pericardial effusion appears in different pathologies such as hydrops fetalis, heart structural or rhythm alterations, however, it can be observed in isolation but an increase in its incidence has been observed in relation to the presence of severe pathologies. METHODS: Analysis of all cases of IFPE detected in Aragon and assessed in a cardiological consultation for prenatal diagnosis of a tertiary hospital collected over ten years, as well as the evolution of the patients to the present. RESULTS: A sample of 38 fetuses was obtained from 37 pregnant women diagnosed with DPFA with spontaneous resolution in 86.8%. Two abortions (voluntary interruptions after prenatal diagnosis of 22q13 deletion and primary infection by cytomegalovirus) and one spontaneous fetal death were recorded. Pathological alterations were observed in 10/38 newborns: two patients with metabolic disease, two patients with chromosomopathies, one patient with pulmonary hypoplasia and unilateral hydronephrosis, one patient with hypertrophic cardiomyopathy, and four patients studied for alterations in psychomotor development and/or congenital ophthalmological or hearing disorders. The overall morbidity rate was 34.2% and death rate 15.7%. The detection of other ultrasound alterations and the alteration in the first trimester screening were significantly associated with the presence of pathology. CONCLUSIONS: IFPE has been classically associated with a good prognosis, although it is sometimes related to clinical entities with high morbidity and mortality: more than a third of the patients in our sample are affected. An exhaustive pre and postnatal follow-up of these cases is recommended in order to perform an early intervention.

Seguimiento del derrame pericárdico fetal aislado: ¿debemos preocuparnos? / Isolated fetal pericardial effusion follow-up: Should we worry?

Introducción y objetivos: El derrame pericárdico fetal aparece en diferentes enfermedades como hidropesía fetal, alteraciones estructurales o del ritmo cardiaco, aunque puede observarse de manera aislada. Se ha observado un incremento de su incidencia con relación a la presencia de enfermedades graves. Métodos: Análisis de la totalidad de casos de derrame pericárdico fetal aislado (DPFA) detectados en Aragón y valorados en consulta cardiológica de diagnóstico prenatal de un hospital terciario recogidos durante 10años, así como la evolución de los pacientes hasta la actualidad. Resultados: Se obtuvo una muestra de 38 fetos en 37 gestantes diagnosticados de DPFA con resolución espontánea en el 86,8%. Se registraron 2abortos (interrupciones voluntarias tras diagnóstico prenatal de deleción 22q13 y de primoinfección por citomegalovirus) y una muerte fetal espontánea. Se objetivaron alteraciones patológicas en 10/38 recién nacidos: 2pacientes con metabolopatía, 2pacientes con cromosomopatía, un paciente con hipoplasia pulmonar e hidronefrosis unilateral, un paciente con miocardiopatía hipertrófica y 4pacientes estudiados por alteraciones del desarrollo psicomotor o alteraciones congénitas oftalmológicas o auditivas. La tasa de morbilidad fue del 34,2% y de fallecimiento del 15,7%. La detección de otras alteraciones ecográficas y la alteración en el cribado del primer trimestre se asociaron de forma significativa con la presencia de patología. Conclusiones: El DPFA se ha asociado clásicamente a buen pronóstico, aunque en ocasiones se relaciona con entidades clínicas con elevada morbimortalidad: más de un tercio de los pacientes en nuestra muestra. Se recomienda un seguimiento estrecho pre y posnatal de estos casos para poder realizar una intervención precoz. (AU)

Introduction and objectives: Fetal pericardial effusion appears in different pathologies such as hydrops fetalis, heart structural or rhythm alterations, however, it can be observed in isolation but an increase in its incidence has been observed in relation to the presence of severe pathologies. Methods: Analysis of all cases of IFPE detected in Aragon and assessed in a cardiological consultation for prenatal diagnosis of a tertiary hospital collected over 10years, as well as the evolution of the patients to the present. Results: A sample of 38 fetuses was obtained from 37 pregnant women diagnosed with DPFA with spontaneous resolution in 86.8%. Two abortions (voluntary interruptions after prenatal diagnosis of 22q13 deletion and primary infection by cytomegalovirus) and one spontaneous fetal death were recorded. Pathological alterations were observed in 10/38 newborns: 2patients with metabolic disease, 2patients with chromosomopathies, one patient with pulmonary hypoplasia and unilateral hydronephrosis, one patient with hypertrophic cardiomyopathy, and 4patients studied for alterations in psychomotor development and/or congenital ophthalmological or hearing disorders. The overall morbidity rate was 34.2% and death rate 15.7%. The detection of other ultrasound alterations and the alteration in the first trimester screening were significantly associated with the presence of pathology. Conclusions: IFPE has been classically associated with a good prognosis, although it is sometimes related to clinical entities with high morbidity and mortality: more than a third of the patients in our sample are affected. An exhaustive pre- and posnatal follow-up of these cases is recommended in order to perform an early intervention. (AU)

Desempeño del método de suma de discos comparado con el método bidimensional en la estimación cuantitativa del derrame pericárdico / Performance of the method of disks compared to the bidimensional method in the quantitative estimation of pericardial effusion

Resumen Introducción: La ecocardiografía bidimensional es la técnica más efectiva para el diagnóstico del derrame pericárdico, gracias a sus altas sensibilidad y especificidad. Objetivo: Analizar la superioridad del método de suma de discos comparado con el método bidimensional en la estimación del derrame pericárdico por medio de ecocardiografía, tomando como referencia el volumen de líquido pericárdico extraído por pericardiocentesis o cirugía abierta. Método: Estudio retrospectivo de seguimiento de una cohorte basado en registros médicos y archivos de ecocardiografía. Se empleó un diseño pareado en el que cada imagen fue leída por el método bidimensional y por el método de suma de discos. Se incluyeron derrames pericárdicos graves, definidos clínicamente o por parámetros ecocardiográficos, que requirieran drenaje. El desempeño de los métodos de estimación bidimensional y de suma de discos, tomando como referencia la extracción por intervención, se cuantificó mediante áreas bajo la curva operador-receptor (auROC). Resultados: Se analizaron 40 registros, tomando como referencia el volumen obtenido por extracción; con un auROC de 0.81 (intervalo de confianza del 95% [IC95%]: 0.73-0.89), el desempeño diagnóstico del método de suma de discos fue significativamente mayor (p = 0.0335) que el del método bidimensional (auROC: 0.73; IC95%: 0.63-0.83). La estimación realizada por el método de suma de discos subestimó en promedio 51.3 ml (IC95%: −156.2-53.5). Conclusiones: En pacientes con derrame pericárdico e indicación de drenaje o taponamiento cardíaco, el método de suma de discos es superior en comparación con el método bidimensional en el estudio ecocardiográfico para la estimación cuantitativa del derrame pericárdico, ya que discrimina mejor respecto al método bidimensional.

Abstract Introduction: Two-dimensional echocardiography is the most effective technique for diagnosing pericardial effusion due to its high sensitivity and specificity. Objective: The superiority of the method of disks was compared with the bidimensional method in the estimation of pericardial effusion by echocardiography, taking as reference the volume of pericardial fluid removed by pericardiocentesis or open surgery. Method: Retrospective follow-up study of a cohort, based on medical records and echocardiography files. A paired design was used, each image was read by the bidimensional method and by the method of disks. Severe pericardial effusions defined clinically or by echocardiographic parameters, that required drainage were included. The performance of the bidimensional and disks estimation methods, taking the volume removed as a reference, was quantified using areas under the receiver operating characteristic curve (auROC). Results: 40 records were analyzed, taking as a reference the volume obtained by extraction, with an auROC of 0.81 (95% CI: 0.73-0.89) the diagnostic performance of the disks method was significantly higher (p = 0.0335) than the bidimensional method (auROC 0.73, 95% CI: 0.63-0.83). The estimate made by the disks method underestimated an average of 51.3 ml (95% CI: -156.2-53.5). Conclusions: In patients with pericardial effusion with indication of cardiac drainage or tamponade, the disks method is superior in comparison with the bidimensional method in the echocardiographic study of the quantitative estimation of pericardial effusion, discriminating better than the bidimensional method.

Utilidad de la tomografía computarizada multicorte para la estimación de la composición del derrame pericárdico / Usefulness of computed tomography densities to estimate the composition of pericardial effusion

Resumen El derrame pericárdico (DP) es una entidad frecuente en la práctica diaria, que puede ocurrir por un amplio rango de patologías. Los métodos por imágenes constituyen una herramienta diagnóstica clave en la evaluación del pericardio. El ecocardiograma transtorácico (ETT) se considera de primera línea por su costo-efectividad. La tomografía computarizada multicorte (TCMC), por su parte, representa un valioso complemento ante limitaciones del ETT y en la evaluación de urgencia del paciente con sospecha de DP. El objetivo del trabajo es mostrar la utilidad y rol de la TCMC, mediante la medición de densidades, para estimar la etiología del DP, ilustrado con casos de nuestra institución.

Abstract Pericardial effusion (PE) is a common entity in daily practice, which can occur due to a wide range of conditions. Imaging methods are a key diagnostic tool in the evaluation of the pericardium. Transthoracic echocardiogram (TTE) is the first line imaging method because of its cost-effectiveness. Multi-slice Computed Tomography (MSCT), on the other hand, represents a valuable complement to the limitations of TTE and in emergency evaluation of the patient with suspected PE. The objective of this review is to show the usefulness and role of the MSCT —through the measurement of densities— to estimate the etiology of PE, illustrated with cases of our Institution.

Pericardite tuberculosa em paciente imunocompetente: relato de caso / Tuberculous pericarditis in an immunocompetent patient: case report

A pericardite tuberculosa é uma forma rara de apresentação de tuberculose extrapulmonar, sendo mais frequente em regiões endêmicas e em pacientes imunocomprometidos. O quadro clínico é na maioria das vezes insidioso, por vezes com sintomas inespecíficos ou com quadro de tamponamento cardíaco. O diagnóstico é feito pela análise do líquido pericárdico ou biópsia pericárdica e o tratamento é realizado com rifampicina, isoniazida, pirazinamida e etambutol. O presente caso relata uma paciente de 51 anos, imunocompetente, com quadro de febre e dispneia há 7 dias. Em tomografia de tórax foi identificado importante derrame pericárdico, sem repercussão hemodinâmica em ecocardiografia transtorácica. A paciente foi submetida à drenagem do derrame pericárdico, com diagnóstico de tuberculose pericárdica pela análise do líquido. Iniciado o tratamento com RHZE, com boa evolução clínica e seguimento ambulatorial.

Tuberculous pericarditis is a rare form of extrapulmonary tuberculosis, being more frequent in endemic regions and in immunocompromised patients. The clinical picture is most often insidious, sometimes with nonspecific symptoms or with cardiac tamponade. Diagnosis is made by analysis of pericardial fluid or pericardial biopsy, and treatment is performed with rifampicin, isoniazid, pyrazinamide, and ethambutol. The present case reports a 51-year-old patient, immunocompetent, with fever and dyspnea for 7 days. A chest tomography showed significant pericardial effusion, without hemodynamic repercussions on transthoracic echocardiography. The patient underwent drainage of the pericardial effusion, with a diagnosis of pericardial tuberculosis by fluid analysis. Treatment with RHZE was started, with good clinical evolution and outpatient follow-up.

Pericardial effusion associated with DRESS syndrome. Case report / Derrame pericárdico asociado con síndrome de DRESS. Reporte de caso

Abstract Introduction: The DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome is a rare but serious and potentially lethal occurrence of a set of signs and symptoms associated with the use certain types of drugs. This syndrome is characterized by a heterogeneous clinical manifestation that, in many cases, results in multisystemic involvement. Case presentation: A 24-year-old man from Calarcá, Colombia, visited the emergency department of the local hospital due to a three-day history of unquantified intermittent fever associated with asthenia, adynamia, anorexia, headache, myalgia, odynophagia, and upper abdominal pain. Due to his condition and based on laboratory findings, he was referred to the Clínica Central del Quindío. The patient, 20 days before the initial assessment, had been prescribed a pharmacological treatment with non-steroidal anti-inflammatory drugs and phenytoin due to a severe cranioencephalic trauma; he also presented with generalized skin rash, elevated transaminases, and moderate eosinophilia. Complementary studies reported mild pericardial effusion, so DRESS syndrome was suspected, and corticosteroid therapy was started, achieving the complete remission of the syndrome. Conclusion: Although the DRESS syndrome has a low incidence, it should always be suspected, especially in patients with cardiac and pericardial involvement. In this case, pericardial involvement was evident, demonstrating that individuals with this syndrome may present with rare symptoms that have a serious impact on their health, as they may significantly increase adverse outcomes and mortality risk.

Resumen Introducción. El síndrome de DRESS (Drug Reaction with Eosinophilia and Systemic symptoms) consiste en la ocurrencia, si bien poco frecuente, pero grave y potencialmente mortal, de un conjunto de signos y síntomas asociados al consumo de cierto tipo de medicamentos. Este síndrome se caracteriza por tener una manifestación clínica heterogénea que, en muchos casos, causa compromiso multisistémico. Presentación del caso. Hombre de 24 años de Calarcá, Colombia, que asistió al servicio de urgencias del hospital local por presentar fiebre intermitente no cuantificada durante 3 días, junto con astenia, adinamia, anorexia, cefalea, mialgias, odinofagia y dolor abdominal superior, y que, debido a su condición y resultados de laboratorio, fue remitido a la Clínica Central del Quindío. El paciente, 20 días antes de la valoración inicial, había recibido tratamiento farmacológico con antiinflamatorios no esteroides y fenitoína por traumatismo craneoencefálico severo; además presentó rash cutáneo generalizado, elevación de transaminasas y eosinofilia moderada. En los estudios complementarios se reportó derrame pericárdico leve, por lo que se sospechó síndrome de DRESS y se inició corticoterapia, lográndose así la remisión completa de la enfermedad. Conclusión. Aunque el síndrome de DRESS tiene una baja incidencia, siempre debe sospecharse, en especial en pacientes que presentan compromiso cardiaco y pericárdico. En este caso se destaca la afectación pericárdica, demostrando que en este síndrome se pueden presentar ma -nifestaciones poco frecuentes, pero con un gran impacto en su salud, ya que pueden aumentar considerablemente los desenlaces adversos y la mortalidad en estos pacientes.

Taponamiento cardíaco y miocarditis en paciente con infección aguda por SARS-CoV-2 / Cardiac tamponade and myocarditis in a patient with acute SARS-CoV-2 infection

Resumen Describimos una paciente con COVID-19, con derrame pericárdico, taponamiento cardíaco y depresión miocárdica grave. Mujer de 51 años, sin enfermedad previa, COVID-19 leve que presentó tres episodios de síncope en domicilio. El electrocardiograma mostró ritmo sinusal, ST de concavidad superior difuso 2 mv; en la tomografía se observó derrame pericárdico y parénquima pulmonar normal. Ingresó a terapia intensiva con shock y requerimiento de asistencia ventilatoria mecánica (AVM). En el ecocardiograma se obser vó derrame pericárdico y taponamiento; se realizó drenaje. El ecocardiograma transesofágico mostró deterioro moderado de función sistólica biventricular; strain longitudinal global -14.2%, Fey estimada: 43%; deformación global circunferencial: -10.1%. A los 7 días del ingreso, la tomografía reveló infiltrados bilaterales y engrosamiento pericárdico con realce post-contraste y derrame pericárdico leve. El día 12 posterior al ingreso, se suspendió el soporte inotrópico; y la paciente, hemodinámicamente estable, se desvinculó de la AVM.

Abstract We describe a patient with COVID-19, with pericardial effusion, cardiac tamponade and severe myocar dial depression. A 51-year-old woman, previously healthy, with mild COVID-19 presented with three episodes of syncope. She was admitted to the emergency room. An electrocardiogram showed sinus rhythm, diffuse superior concavity ST 2 mv; a CT scan showed pericardial effusion, without lung pathological findings. Due to shock, dyspnoea and encephalopathy, the patient was admitted to intensive care, where she received vasopressor support and mechanical ventilation. A bedside ultrasound showed pericardial effusion and tamponade; drainage was performed; transoesophageal ultrasound showed moderate deterioration of biventricular systolic function; global longitudinal strain -14.2%, estimated Fey 43%; global circumferential strain -10.1%. Seven days after admission, CT scan revealed bilateral infiltrates and pericardial thickening with post-contrast enhancement and mild pericardial effusion. On day 12 post admission, inotropic support was discontinued; patient on mechanical ventilation weaning and haemodynamically stable.

Hemopericardio masivo por sobreanticoagulación en portador de prótesis valvular mecánica: Reporte de caso / Massive hemopericardium due to overanticoagulation in a patient with mechanical valve prothesis: Case Report

Introducción: Los derrames pericárdicos masivos representan menos del 2% de las complicaciones de los post operados de cirugía cardíaca. Reporte de caso: Varón de 31 años, portador de prótesis mitral mecánica, que reingresa a la tercera semana de la cirugía por hemopericardio masivo e INR en 6,23. Fue sometido a ventana pleuropericárdica de emergencia, drenando un volumen de 1500ml. Conclusiones: Es necesario un seguimiento sistemático para mantener un rango de anticoagulación deseado e identificar tempranamente posibles complicaciones.

Background:Massive pericardial effusion represents less than 2% of cardiac surgery complications. Male, 31 years old, with Case Report:mechanical mitral valve, who were readmitted three weeks after cardiac surgery, due to massive hemopericardium and INR of 6,23. He underwent the pericardial window through the left mini-thoracotomy, draining 1500ml. It is necessary a systematic monitoring Conclusions:to maintain desired anticoagulation values and to identify possible complications early

La historia (des)conocida de las incisiones torácicas. Segunda parte: De las primeras pericardiotomías al nacimiento de la esternotomía longitudinal media

RESUMEN Durante el siglo XIX se constataron más avances en la cirugía torácica que los experimentados en las más de 40 centurias transcurridas desde la escritura del papiro de Edwin Smith. En un período de poco menos de cien años el hombre abordó la cavidad pericárdica no solo para evacuar derrames, sino para suturar satisfactoriamente heridas en el músculo cardíaco. Además, se realizaron las primeras toracotomías con la específica intención de resecar segmentos pulmonares y se abrió por primera vez el esternón en toda su longitud, un abordaje que con el paso del tiempo se convertiría en la más usada de todas las incisiones torácicas. La mayoría de los cirujanos torácicos conoce poco acerca del verdadero origen de muchos de estos procedimientos quirúrgicos que se emplean en los salones de operaciones del siglo XXI. Esta segunda parte de nuestra revisión tiene la intención de seguir develando la desconocida historia de las incisiones torácicas.

ABSTRACT The 19th century saw more advances in thoracic surgery than in the more than 40 centuries since the writing of the Edwin Smith papyrus. In a period of less than a century, man approached the pericardial cavity not only to drain effusions, but to successfully suture wounds in the cardiac muscle. Moreover, the first thoracotomies were performed for the specific purpose of resecting lung segments and the sternum was completely opened for the first time, an incision that would eventually become the most widely used of all thoracotomies. Most thoracic surgeons know little about the true story behind many thoracotomies performed in the operating rooms of the 21st century. This second part of our review further unveils the unknown history of thoracic incisions.

Linfoma pericárdico primario a células T/NK: reporte de un caso / Primary pericardial T/NK cell lymphoma: case report / Linfoma pericárdico primário de células T/NK: relato de um caso

Los linfomas cardíacos primarios son un subtipo muy poco frecuente de tumor en los cuales la lesión primaria se encuentra en el corazón. Los tumores suelen ser infiltrantes y se localizan en la aurícula derecha, seguidos del pericardio. Su mortalidad es notablemente alta y el diagnóstico tardío es el principal factor para su mal pronóstico. Describimos el caso de un paciente que presentó shock obstructivo por derrame pericárdico profuso causado por un tipo raro de tumor cardíaco primario, un linfoma pericárdico de células T/NK.

Primary cardiac lymphomas are a rare subtype of lymphomas in which the primary lesion is in the heart. The tumors are usually located in the right atria, followed by the pericardium and are frequently infiltrative. Mortality is remarkably high in this group and the delayed diagnosis is the main factor for its poor prognosis. We describe the case of a patient that presented with obstructive shock due to profuse pericardial effuse caused by a rare kind of primary cardiac tumor, a T/NK cell pericardial lymphoma.

Os linfomas cardíacos primários são um subtipo de tumor muito raro, no qual a lesão primária está no coração. Os tumores geralmente são infiltrativos e localizam-se no átrio direito, seguidos pelo pericárdio. Sua mortalidade é notavelmente alta e o diagnóstico tardio é o principal fator que produz seu mau prognóstico. Descrevemos o caso de um paciente que apresentou choque obstrutivo devido a um derrame pericárdico profuso causado por um tipo raro de tumor cardíaco primário, um linfoma pericárdico de células T/NK.

[Isolated fetal pericardial effusion follow-up: Should we worry?] / Seguimiento del derrame pericárdico fetal aislado: ¿debemos preocuparnos?

INTRODUCTION AND OBJECTIVES: Fetal pericardial effusion appears in different pathologies such as hydrops fetalis, heart structural or rhythm alterations, however, it can be observed in isolation but an increase in its incidence has been observed in relation to the presence of severe pathologies. METHODS: Analysis of all cases of IFPE detected in Aragon and assessed in a cardiological consultation for prenatal diagnosis of a tertiary hospital collected over 10years, as well as the evolution of the patients to the present. RESULTS: A sample of 38 fetuses was obtained from 37 pregnant women diagnosed with DPFA with spontaneous resolution in 86.8%. Two abortions (voluntary interruptions after prenatal diagnosis of 22q13 deletion and primary infection by cytomegalovirus) and one spontaneous fetal death were recorded. Pathological alterations were observed in 10/38 newborns: 2patients with metabolic disease, 2patients with chromosomopathies, one patient with pulmonary hypoplasia and unilateral hydronephrosis, one patient with hypertrophic cardiomyopathy, and 4patients studied for alterations in psychomotor development and/or congenital ophthalmological or hearing disorders. The overall morbidity rate was 34.2% and death rate 15.7%. The detection of other ultrasound alterations and the alteration in the first trimester screening were significantly associated with the presence of pathology. CONCLUSIONS: IFPE has been classically associated with a good prognosis, although it is sometimes related to clinical entities with high morbidity and mortality: more than a third of the patients in our sample are affected. An exhaustive pre- and posnatal follow-up of these cases is recommended in order to perform an early intervention.

Taponamiento cardíaco por hemopericardio atraumático / Nontraumatic hemopericardium and cardiac tamponade

Objetivo: el taponamiento cardiaco por causas clínicas es una entidad rara y de difícil diagnóstico. Metodología: se reporta el caso de una paciente atendida en el nivel de mediana complejidad por taponamiento cardiaco de origen oncológico de novo. Se analiza la fisiopatología del derrame, causas etiológicas del taponamiento cardiaco, presentación clínica, valor de las ayudas diagnósticas a la mano en estos casos y las utilizadas en situaciones especiales, así como el manejo de esta patología

Objective: Cardiac tamponade for clinical causes is a rare and difficult to diagnose entity. Methodology: we report the case of a female patient treated at a mid-level hospital for cardiac tamponade due to de novo metastatic disease. The physiopathology of the effusion, etiological causes, clinical manifestations, value of diagnostic aids available for these cases and those used in special situations, as well as the management of this pathology, were analyzed

Derrame pericárdico en pacientes embarazadas / Pericardial effusion in pregnant patients

RESUMEN Introducción: El derrame pericárdico en la paciente embarazada es infrecuente, pero se ha visto su presencia en algunos casos aislados sin repercusión hemodinámica, por lo que no se describe la evolución y la conducta a seguir en estas pacientes. Objetivos: Caracterizar a la paciente embarazada con derrame pericárdico, según variables clínicas, epidemiológicas y de laboratorio; y determinar el tiempo de evolución del derrame pericárdico posterior al parto. Método: Se realizó un estudio observacional descriptivo prospectivo con 15 embarazadas con diagnóstico de derrame pericárdico, definido por ecocardiograma transtorácico, seleccionadas de forma intencional de una población de 256 mujeres en estado de gravidez, que fueron atendidas en el Hospital Universitario Gineco-Obstétrico Mariana Grajales de la ciudad de Santa Clara (Villa Clara, Cuba) durante el período de julio 2018 a marzo 2019. Resultados: De las 256 pacientes, solo 15 (5,9%) presentaron derrame pericárdico. El 80% de estos derrames fue encontrado en pacientes con preeclampsia. El 66,7% tenía entre 20 y 29 años de edad, y el 73,3%, color blanco de piel. El derrame fue predominantemente leve (66,7%) y nunca grave, y las pacientes afectadas tenían, además, hipertensión arterial crónica (40%), obesidad (20%) y enfermedad del colágeno (13,3%). En el 86,7% de los casos el derrame pericárdico desapareció en los primeros 15 días posparto. Conclusiones: El derrame pericárdico fue encontrado con más frecuencia en pacientes con preeclampsia, hipertensión arterial crónica, obesidad, proteinuria, hipoproteinemia e hipoalbuminemia; y desapareció, en la mayoría de los casos, en los primeros 15 días posparto.

ABSTRACT Introduction: Pericardial effusions are infrequent in pregnant patients, but its presence has been seen in some isolated cases without hemodynamic involvement. Therefore, neither outcome nor treatment of these cases are described. Objectives: To characterize pregnant patients with pericardial effusion, according to clinical, epidemiological and laboratory variables and determine the recovery time from post-delivery pericardial effusion. Method: A prospective descriptive observational study was carried out with 15 pregnant women with pericardial effusion, diagnosed by transthoracic echocardiogram, intentionally selected from a population of 256 pregnant women who were treated at the Hospital Universitario Gineco-Obstétrico Mariana Grajales in the city of Santa Clara (Villa Clara, Cuba) during the period from July 2018 to March 2019. Results: Of the 256 patients, only 15 (5.9%) presented pericardial effusion. Eighty percent of these effusions were found in patients with pre-eclampsia. A total of 66.7% were aged between 20 and 29 years and 73.3% were white. Effusions were predominantly mild (66.7%) and never severe, and the affected patients also had chronic high blood pressure (40%), obesity (20%) and collagen disease (13.3%). In 86.7% of cases the pericardial effusion resolved in the first 15 days postpartum. Conclusions: Pericardial effusion was more frequently found in patients with pre-eclampsia, chronic arterial hypertension, proteinuria, hypoproteinemia and hipoalbuminemia, and in most cases resolved within the first 15 days postpartum.

Caso Clínico: Mesotelioma primario de pericardio / Case Report: Primary Pericardial Mesothelioma / Case Report: Primary Pericardial Mesothelioma

INTRODUCCIÓN: El mesotelioma primario de pericardio (MPP) es un tumor de origen mesodérmico muy raro dentro de las patologías oncológicas; con una incidencia muy baja. Se han descrito aproximadamente 350 casos alrededor del mundo, siendo la mayoría diagnósticos post mortem. El pronóstico es malo a corto plazo, independientemente del tratamiento a instaurarse, siendo este por lo general únicamente paliativo. A continuación presentamos un caso clínico a propósito de esta patología. CASO CLÍNICO: Paciente de 69 años hospitalizado con cuadro de disnea progresiva y anemia severa. En exámenes complementarios de imagen se evidenció derrame pleural y derrame pericárdico. El reporte histopatológico del líquido pericárdico fue positivo para mesotelioma pericárdico. EVOLUCIÓN: Debido a derrame pericárdico recurrente se decidió realizar pericardiectomía más pleurectomía izquierda como tratamiento paliativo, para aliviar la sintomatología del paciente. Se propuso continuar con quimioterapia, sin embargo, el estado general del paciente se deterioró llevando al fallecimiento. CONCLUSIÓN: El mesotelioma primario de pericárdico es un tumor extremadamente raro, cuya clínica se caracteriza por sintomatología asociada al derrame pericárdico, siendo debido a su baja incidencia un diagnóstico difícil. El pronóstico es malo a corto plazo y no se encuentra un protocolo establecido con resultados que mejoren la mortalidad.

BACKGROUND: Primary pericardial mesothelioma is an extremely rare mesodermal tumor, among oncological diseases, with a very low incidence. About 350 cases have been described around the world, most of them diagnosed post-mortem. The short term prognosis is poor, regardless of the treatment, which is mostly palliative. We present a case report regarding this pathology. CASE REPORT: 69 year old patient hospitalized with dyspnea and severe anemia. Complementary workup showed pleural effusion and pericardial effusion. Histopathology report of the pericardial fluid revealed pericardial mesothelioma. EVOLUTION: Due to recurrence of pericardial effusion, it was decided to perform pericardiectomy and left pleurectomy as palliative treatment, to alleviate the patient's symptoms. Chemotherapy was planned after the procedure, but the patient's general condition deteriorated severely leading to his death. CONCLUSION: Primary pericardial mesothelioma is a rare tumor, whose symptoms are characterized by the associated pericardial effusion, making the diagnosis difficult due to it low incidence. The prognosis is poor in short- term, and there isn't an established protocol for the treatment with results that showed improve in mortality.