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A4094 - Cardiac Tamponade Secondary to Hemopericardium Revealing Two Malignancies: Lung Adenocarcinoma and Chronic Lymphocytic Leukemia (CLL)
Author Block: A. Husain, A. Mohammed, G. Elnema, B. Pearlman; Internal Medicine, Wellstar Atlanta Medical Center, Atlanta, GA, United States.
Pericardial involvement is seen in 20% of cancer patients however, tamponade is rarely the initial presentation1. Prompt recognition is required for timely diagnosis and intervention. We report a case of cardiac tamponade in a patient who was diagnosed with both lung adenocarcinoma and chronic lymphocytic leukemia. 61 year-old African American male with no significant past medical history presented to the emergency room (ER) with subjective, fever, chills and night sweats for three days. Further history revealed gradual worsening shortness of breath on exertion since one week, dry non-productive cough, epigastric discomfort, 40 pack years of cigarette smoking and occasional marijuana use. On presentation he was tachycardic, tachypneic with a low normal blood pressure and auscultation revealed muffled heart sounds, but no significant JVD, Kussmaul sign or pulsus paradoxus. Initial work up in the ER showed normal complete metabolic profile, cardiac enzymes and BNP. Complete blood count showed mild leukocytosis and lactate 4.9. CXR and EKG were unremarkable, however, a bedside ultrasound showed a large pericardial effusion. A stat echocardiogram revealed tamponade physiology and the patient underwent emergent pericardiocentesis with removal of 910 cc of bloody exudative fluid per light’s criteria. Infectious and autoimmune workup was negative. Initial cytology was suggestive of adenocarcinoma, however, CT scans of chest abdomen and pelvis were negative except for mediastinal lymph node enlargement. Lung adenocarcinoma was strongly suspected due to positive TTF-1 and Napsin-A. Further testing of tumor cells for drivers showed 90% PDL-1 reactivity, negative ALK, ROS1 and EGFR. In addition, flow cytometry of blood and pericardial fluid was consistent with CLL. Bronchoscopy was negative for endobronchial lesion and biopsy of paratracheal lymph node was inconclusive. MRI head and bone scan was negative for metastasis and repeat echo on day 10 did not show any reaccumulation upon which patient was discharged with close follow-up and treated with pembrolizumab. This case illustrates the importance of suspecting tamponade even in absence of physical exam, EKG and X-ray findings. A prompt bedside ultrasound and subsequent echocardiogram may result in earlier life saving intervention. Furthermore, it is extremely rare to find two different types of malignancies on cytology from pericardial effusion. TTF-1 and Napsin-A double staining can be helpful in confidently diagnosing lung adenocarcinoma even when no obvious lesions are identified on initial imaging or bronchoscopy and other possibilities are ruled out.2