Cardiac tamponade: an unusual cause. Clinical case

The Authors describe an unusual case of acute cardiac tamponade caused by fistulization in the pericardial cavity of an amebic abscess of the left lobe of the liver. The availability of echocardiography facilitated prompt diagnosis and treatment.     

Xanthogranulomatous Cholecystitis with a Liver Abscess and Metastatic Endophthalmitis: Report of a Case

There have been no reported cases of xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis in the literature. There has been only one other case of xanthogranulomatous cholecystitis associated with a liver abscess in Japan prior to the present report. A 53-year-old man was admitted to a local hospital complaining of high fever. Abdominal ultrasonography and computed tomography showed a liver abscess. After percutaneous transhepatic abscess drainage, he complained of an abnormal sensation in his left eyeball and was diagnosed to have endophthalmitis. After being treated for the endophthalmitis, he was referred to our hospital to have the liver abscess evaluated. Endoscopic retrograde cholangiopancreatography showed a normal biliary system without any communication with the liver abscess. Two weeks after endoscopic retrograde cholangiopancreatography he complained of right hypochondralgia. Ultrasonography revealed the presence of sludge in the swollen gallbladder. Under a diagnosis of cholecystitis with a liver abscess, a cholecystectomy was performed. A histological examination indicated xanthogranulomatous cholecystitis based on the findings of a granulomatous lesion consisting of foamy cells in the gallbladder wall. We herein present the first known case of xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis, while also making a review of the literature. Received: December 21, 2000 / Accepted: September 11, 2001     

Amebic liver abscess rupturing into the lesser omentum space

A case of an amebic abscess localized in the lesser omentum is reported. There was no sign of a liver abscess in the imaging examination or the operative findings. However, it is likely that the amebic infection occurred after a liver abscess ruptured into the abdominal cavity. Early diagnosis and therapy are required when an abscess of unknown origin borders the liver, given the possibility of amebic abscess.     

Delayed presentation of perisplenic abscess following arterial embolization

INTRODUCTIONSplenic abscess formation is a rare but significant complication that may occur after non-operative management (NOM) of a blunt splenic injury (BSI). we describe an unusual case of perisplenic abscess formation nearly 4 months after splenic artery angioembolization for a grade III splenic laceration.PRESENTATION OF CASEA 52-year-old male was transferred to the Emergency Department (ED) of our institution after falling off his bicycle. He was hemodynamically stable but complained of left upper quadrant pain. Computed tomography (CT) was notable for a Grade III splenic laceration. The patient underwent a successful splenic artery embolization on hospital day 1. He had an uneventful post-embolization course and was discharged 3 days later, afebrile, with a stable hematocrit. Four months after his initial presentation, the patient presented to the ED with fever, malaise, and left upper quadrant abdominal pain. A CT scan revealed a multiloculated perisplenic abscess. He underwent a splenectomy and drainage of peri-splenic abscess, received a course of antibiotics, and had an uneventful recovery.DISCUSSIONNOM including splenic angioembolization (SAE) is the standard of care for blunt splenic trauma in hemodynamically stable patients. Known complications from SAE include bleeding, missed injuries to the diaphragm and pancreas, and splenic abscess. This report documents a delayed perisplenic abscess following NOM of blunt splenic trauma, a rare but potential complication of SAE.CONCLUSIONFormation of a perisplenic abscess may occur several months after NOM of a blunt splenic injury. Prompt surgical management and antibiotic therapy are critical to avoid life-threatening complications.     

A case of amebic liver abscess rupturing into the stomach

A forty-eight year-old man complained of upper abdominal pain and diarrhea with mucinous bloody stool. He had not been abroad. Except high fever, anemia, leukocytosis and elevated rate of erythrocyte sedimentation, laboratory findings were not abnormal. Gastrofiberscopy showed the protrusion of gastric mucosa with a hollow on its surface in the angle. Abdominal CT scan and echogram revealed an abscess in the right hepatic lobe and an abscess in the left lobe. Ulceration and small protrusion of the rectal mucosa were found by romanoscopy. Stool examinations could not reveal amebas, but serological test for amebiasis by the Ouchterlony method showed positive. Under the diagnosis of the perforation into the stomach of amebic liver abscess, he was treated with Metronidazole and tetracycline. But, as a diffuse shadow appeared in the right thoracic cavity on the chest x-ray films with bloody sputa, perforation of amebic liver abscess to the right thoracic cavity was suspected. Laparotomy showed the communication of the abscess to gastric lumen. The post operative course was uneventful. We reported a case with the rare complication of amebic liver abscess.     

Amebic pericardial effusion: a rare complication of amebic liver abscess.

Two rare cases of amebic pericardial effusion as a complication of amoebic liver abscess in the left lobe are described. The pericardial amebiasis should be suspected in a patient presenting with signs and symptoms of pericardial effusion with an evidence of hepatic abscess (in the left lobe) or in a patient with pericardial effusion of uncertain etiology. Aspiration of "anchovy sauce" pus from both the pericardial cavity and the liver should be regarded as confirming the diagnosis of amebic pericarditis secondary to amebic liver abcess because demonstration of Entamoeba hystolytica is seldom possible. Removal of pericardial pus and metronidazole intake were markedly effective in treating our patients.     

An Amebic Lung Abscess: Report of a Case

Recently the number of amebiasis cases has increased in Japan. Pleuropulmonary amebiasis is a very rare complication of liver amebiasis. We report herein the case of a 54-year-old man presenting with an amebic lung abscess in his right lower lung. The diagnosis of lung amebiasis was established from a direct examination of the pus in which trophozoites of Entamoeba histolytica were detected. After the oral administration of metronidazole, the laboratory findings improved and he thus underwent a right lower lobectomy. He was discharged without any relapse of infection 20 days after a thoracotomy. We conclude that a protozoan infection should thus be suspected in the case of a pleuropulmonary infection in which several types of antibiotics prove to be ineffective. Received: January 29, 2001 / Accepted: May 15, 2001     

Anesthesia for pericardial window in a pregnant patient with cardiac tamponade and mediastinal mass

PURPOSE: To present a case report of anesthesia for pericardial window surgery for acute cardiac tamponade in a patient with an anterior mediastinal mass in late pregnancy. CLINICAL FEATURES: A 34-yr-old gravida 2, para 1 patient presented at 29 weeks gestation with dyspnea, orthopnea, chest pain, and cough. Investigations showed an anterior mediastinal mass due to Hodgkin's disease. A course of vinblastine at 31 weeks gestation resulted in symptomatic improvement but at 34 weeks gestation she developed an acute cardiac tamponade for which pericardial window drainage was required. Additional help and equipment were assembled in case of cardiopulmonary deterioration. Intra-arterial pressure and continuous fetal monitoring were established and iv access was secured in both arms and the left foot. After awake fibreoptic intubation, spontaneous ventilation was maintained. Anesthesia consisted of local anesthetic infiltration of the anterior chest wall, supplemented with fentanyl, midazolam, and ketamine. The patient remained stable, was extubated fully awake, and then monitored in an intensive care area. CONCLUSION: This patient presented with acute cardiac tamponade and an anterior mediastinal mass in late pregnancy, an unusual combination of challenges that requires a careful approach to anesthetic management.     

Patch closure and patch angioplasty for a coronary aneurysm after percutaneous coronary intervention

The patient was a 67-year-old man who complained of shortness of breath. Coronary angiography showed 90% stenosis in proximal left anterior descending (LAD). He therefore underwent a directional coronary atherectomy (DCA). During the procedure, coronary artery perforation occurred at the origin of the LAD, which caused cardiac tamponade. Surgical pericardial drainage was done. Though bleeding was successfully controlled and his general condition improved, coronary angiography showed a coronary aneurysm at the site of the perforation 2 weeks later. Patch closure of the coronary aneurysm and patch angioplasty of the left main coronary artery were performed. Distal LAD was bypassed with the left internal thoracic artery in case of acute thrombosis. He recovered uneventfully and was discharged 14 days after operation.     

Rupture of the heart in a burn patient: a case report of free wall rupture of the left ventricle.

A 63-year-old male was burned when in a state of alcoholic intoxication, he fell head first into a bathtub filled with hot water and received burns covering 40 per cent BSA. Despite surgical wound debridement, a severe sepsis continued and a sudden cardiac arrest occurred. Autopsy revealed a large volume of blood in the pericardial space. The heart was ruptured through a myocardial abscess in the posterior wall of the left ventricle. The principle cause of his death was attributed to acute cardiac tamponade following cardiac rupture through a myocardial abscess.     

A case of cardiac tamponade shock due to bleeding from an advanced thymoma

Although thymomas are the most common anterior mediastinal neoplasm, those causing cardiac tamponade are unusual. To the best of our knowledge, only 13 cases have been proven in the English literature We report thymoma in a 66-year old man that caused cardiac tamponade, for which he underwent an emergency operation. On admission, he presented in a shocked state; his echocardiography results revealed pericardial effusion. Computed tomography scan indicated a thymoma infiltrating the right lung. Initially, pericardial drainage was performed through puncture; however, cardiac tamponade recurred next day. Pericardial drainage, thymectomy, and pericardiectomy were performed, but the tumor was incompletely resected. On postoperative day 2, right upper lobectomy was attempted but discontinued because of the impossibility to manipulate the pulmonary hilum, which was suspected to have tumor infiltration. He was discharged on the 27th day after the first operation, is alive at 10 months after surgery, and is under chemotherapy.     

An elderly case of ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade

We reported a case of successful aortic arch replacement using selective cerebral perfusion for ruptured distal aortic arch aneurysm (DAAA) with cardiac tamponade. A 80-year-old man who had preoperative episode of severe chest pain. Computed tomography showed saccular DAAA and pericardial effusion. He was diagnosed as ruptured DAAA with hemorrhagic cardiac tamponade. We performed urgent graft replacement of the aortic arch using selective cerebral perfusion. Postoperatively he had no complication. Thirty days after the operation he was discharged from the hospital and he is now leading a normal life.     

Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report

IntroductionTraumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade.Presentation of caseA 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot.DiscussionAlthough the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient’s life-threatening condition.ConclusionA prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space.     

Non-perforating pericardial rupture causing cardiac tamponade

A 51-year-old auto truck driver was transferred to our hospital after crashing. He had a severe pain on the left anterior chest wall with high central venous pressure of 30 cm H(2)O. Surveillance of the chest revealed cardiac tamponade and the right seventh rib fracture with left pleural effusion. Pericardiotomy through median sternotomy led to extrusive bloody pericardial effusion. Non-perforating pericardial laceration at the site of the adjoining muscular structure of the diaphragm was repaired with direct suture closure. His postoperative course was uneventful.     

Atrial rupture in a child from cardiac massage by his parent

A 4-year-old boy presented with a single seizure following a viral syndrome. He had a pericardial effusion on admission, and this increased suddenly on the third day of hospitalization, producing cardiac tamponade. After blood was aspirated from the child's pericardial cavity, the father revealed that he performed cardiac massage on his son following the seizure. A laceration of the right atrium was repaired at operation, and the boy made a good recovery. Cardiopulmonary resuscitation by lay persons is not without hazard, and patients with such a history should be watched carefully for the possibility of damage to intrathoracic structures.     

Anuric Acute Renal Failure Associated with Pericardial Effusion without Signs of Cardiac Tamponade

This article describes the anuric acute renal failure (ARF) secondary to massive pericardial effusion without tamponade in an 84 year-old man. He was referred to our emergency room with progressive dyspnea and azotemia. An electrocardiogram showed sinus tachycardia. A two-dimensional echocardiogram confirmed the presence of severe pericardial effusion without prominent ventricular diastolic collapse and there were no changes in his vital signs. Laboratory findings showed that his blood urea nitrogen and serum creatinine levels were 91.8 and 3.77 mg/dL, respectively. Renal ultrasonography showed no signs of hydronephrosis. Urine output did not increase in spite of giving a saline and furosemide infusion but increased immediately after pericardiocentesis with drainage. His renal function was completely restored 3 days after the procedure. A pericardial biopsy demonstrated invasion of malignant cells. We should keep in mind that pericardial effusion is one of the causes of anuric ARF, although it is not accompanied by tamponade.     

Anuric Acute Renal Failure Associated with Pericardial Effusion without Signs of Cardiac Tamponade

This article describes the anuric acute renal failure (ARF) secondary to massive pericardial effusion without tamponade in an 84 year-old man. He was referred to our emergency room with progressive dyspnea and azotemia. An electrocardiogram showed sinus tachycardia. A two-dimensional echocardiogram confirmed the presence of severe pericardial effusion without prominent ventricular diastolic collapse and there were no changes in his vital signs. Laboratory findings showed that his blood urea nitrogen and serum creatinine levels were 91.8 and 3.77 mg/dL, respectively. Renal ultrasonography showed no signs of hydronephrosis. Urine output did not increase in spite of giving a saline and furosemide infusion but increased immediately after pericardiocentesis with drainage. His renal function was completely restored 3 days after the procedure. A pericardial biopsy demonstrated invasion of malignant cells. We should keep in mind that pericardial effusion is one of the causes of anuric ARF, although it is not accompanied by tamponade.     

A successful repair of post-infarction left ventricular free wall rupture

Left ventricular free wall rupture secondary to acute myocardial infarction is almost invariably fatal. This report is the case presentation of a successful repair of left ventricular free wall rupture. A 55-year-old man, with a diagnosis of acute infero-lateral myocardial infarction, was transferred from another hospital to our CCU having recurrent chest pain on the fourth day after infarction. Shortly after admission, he lost his consciousness and fell into cardiogenic shock. Echocardiography showed a large pericardial fluid. He was immediately transferred to the operating room with the diagnosis of the heart rupture. After opening the pericardium containing 200 cc of blood, cardiac tamponade was relieved. The posterolateral portion of the left ventricle was found to be bluishly discolored, with a 8 mm-long tear of epicardium. Using cardiopulmonary bypass, the tear was closed with Teflon-reinforced sutures. The post-operative course was uneventful.     

Emergent surgical treatment for purulent pericarditis associated with cardiac tamponade; report of a case

We describe a case of purulent pericarditis presented with cardiac tamponade. A 65-year-old man was admitted to our hospital with shock by cardiac tamponade and high grade fever. Transthoracic echocardiography revealed a large amount of pericardial effusion. Surgical drainage via median sternotomy was carried out in an emergent manner. Because culture of pericardial effusion showed positive for methicillin sensitive Staphylococcus aureus and thick white purulence covering over all pericardium, purulent pericarditis was diagnosed. Postoperative course was uneventful and discharged in a good condition. Special care should be taken of purulent pericaditis in differential diagnosis of cardiac tamponade.     

Gas-forming liver abscess after transcatheter arterial embolization for hepatocellular carcinoma: Report of a case

A case of a gas-forming liver abscess developing after transcatheter arterial embolization for recurrent hepatocellular carcinoma (HCC) in a 65-year-old man is presented herein. He was admitted to hospital with fever and jaundice, following which ultrasonography (US) and computed tomography revealed a gas-containing abscess in the posterior segment of the hepatic lobe with multiple HCC. Percutaneous transhepatic drainage was performed using US. Antibiotics which were sensitive to theEscherichia coli bacteria detected in the abscess were administered both intravenously and through the drainage tube into the abscess. Four months later, the abscess had diminished and the patient was discharged after receiving percutaneous ultrasonographically guided ethanol injection therapy for the recurrent HCC.