Fatal cardiac tamponade in a patient with Kawasaki disease

Kawasaki disease (KD) is usually a self-limiting condition, but cardiac complications are not uncommon and can lead to significant morbidity and mortality. This article describes the case of an 18-year-old man with rapidly progressive and ultimately fatal KD. Polyserositis syndrome and cardiac tamponade developed during a convalescent phase of the illness. Treatment with high-dose corticosteroid and intravenous immunoglobulin-G therapy was unsuccessful. The patient continued to deteriorate despite supportive care. Severe cardiac tamponade developed, and percutaneous pericardiocentesis was performed, but the patient died hours later. This is the second reported case of KD featuring a polyserositis syndrome and impending cardiac tamponade, and the first with fatal outcome.     

Low-pressure cardiac tamponade.

An elderly man developed cardiac tamponade from a tuberculous pericardial effusion but without such typical manifestations as pulsus paradoxus and jugular-vein distension. This case illustrates the difficulties in clinical recognition of low-pressure cardiac tamponade, which can develop in the presence of dehydration and hypovolemia. The hemodynamic factors that account for this phenomenon are discussed.     

Juvenile rheumatoid arthritis with cardiac tamponade.

A 4-year-old girl with seronegative systemic juvenile rheumatoid arthritis developed acute cardiac tamponade. Pericardiocentesis and systemic corticosteroids resulted in complete recovery of the pericardial involvement. This was followed by complete remission of rheumatoid disease.     

Long-term cardiac sequelae of Kawasaki disease

Kawasaki disease is the leading cause of acquired heart disease in childhood. Despite treatment with intravenous gamma globulin, 2% to 4% of patients have coronary abnormalities. Those with giant aneurysms are at risk for stenosis and myocardial ischemia/infarction, and require aggressive anticoagulation with frequent follow-up, including stress testing and coronary angiography. In rare cases, patients will have coronary artery bypass grafting. Those with less severe coronary involvement need antiplatelet therapy and infrequent noninvasive testing. Patients with normal echos after the acute phase are not treated, but the future impact of the disease is not certain particularly in the setting of adult onset coronary artery disease.     

Systemic lupus erythematosus presenting with cardiac tamponade.

A previously well 36 year old man presented with cardiac tamponade as the initial manifestation of systemic lupus erythematosus. This diagnosis should, therefore, be considered not only in cases of pericarditis but also in those of tamponade.     

Primary cardiac angiosarcoma associated with cardiac tamponade: case report.

A 57-year-old male with primary cardiac angiosarcoma was initially admitted for cardiac tamponade. Pericardiocentesis was performed twice preoperatively, but the bloody pericardial fluid was cytologically negative for malignant cells. The tumor in the right atrium was resected during cardiopulmonary bypass. The resected tumor was 5.5x4.5x3.0cm in size and the diagnosis of cardiac angiosarcoma was made histologically. There were no tumor cells in the surgical margin. Unfortunately the patient died 3.5 months after surgery due to multiple recurrence in the pericardium. A suitable therapy for cardiac angiosarcoma is still controversial, but early antemortem diagnosis and more aggressive combined treatment should be considered.     

Occult cardiac lymphoma presenting with cardiac tamponade

Subxiphoid pericardiostomy is the procedure of choice for treatment of a pericardial effusion with tamponade. We report a case in which this procedure not only failed to reveal the presence of an occult malignancy, but also resulted in a recurrent symptomatic effusion.     

Myxedema associated with cardiac tamponade

Pericardial effusion is frequently found in patients diagnosed with hypothyroidism, yet it is rarely associated with cardiac tamponade. This report presents an atypical case concerning a 60-year-old Taiwanese female, with a history of thyroidectomy surgery due to thyroid cancer, who was later diagnosed with myxedema and cardiac tamponade. Treatment included an immediate pericardiocentesis followed by thyroxine hormone replacement therapy. Postoperative and recovery phases progressed favorably, and the patient's prognosis is good.     

Paradoxical hypertension with cardiac tamponade

Subacute (medical) tamponade develops over a period of days or even weeks. Previous studies have shown that subacute tamponade is uncommonly associated with hypotension. On the contrary, many of those patients are indeed hypertensive at initial presentation. We sought to determine the prevalence and predictors of hypertensive cardiac tamponade and hemodynamic response to pericardial effusion drainage. We conducted a retrospective study of patients who underwent pericardial effusion drainage for subacute pericardial tamponade. Diagnosis of pericardial tamponade was established by the treating physician based on clinical data and supportive echocardiographic findings. Patients were defined as hypertensive if initial systolic blood pressure (BP) was ≥140 mm Hg. Thirty patients with subacute tamponade who underwent pericardial effusion drainage were included in the analysis. Eight patients (27%) were hypertensive with a mean systolic BP of 167 compared to 116 mm Hg in 22 nonhypertensive patients. Hypertensive patients with tamponade were more likely to have advanced renal disease (63% vs 14%, p <0.05) and pre-existing hypertension (88% vs 46, p <0.05) and less likely to have systemic malignancy (0 vs 41%, p <0.05). Systolic BP decreased significantly in patients with hypertensive tamponade after pericardial effusion drainage. Those results are consistent with previous studies with an estimated prevalence of hypertensive tamponade from 27% to 43%. In conclusion, a hypertensive response was observed in approximately 1/3 of patients with subacute pericardial tamponade. Relief of cardiac tamponade commonly resulted in a decrease in BP.     

Kawasaki disease.

INTRODUCTION: Kawasaki disease (KD) is the leading cause of acquired heart disease among children in developed nations. Its incidence has risen in recent years and 20% of untreated patients develop coronary artery abnormalities. OBJECTIVES: To analyze the epidemiological, clinical, laboratory and echocardiographic data of cases diagnosed in Hospital Fernando Fonseca and to identify factors that may influence prognosis. POPULATION AND METHODS: A retrospective study was performed of all children admitted to Hospital Fernando Fonseca with Kawasaki disease between June 1996 and December 2003. Diagnosis was based on the presence of fever plus four of the classic criteria or three of them in association with coronary aneurysms. Demographic and clinical features, laboratory and imaging findings, therapeutic measures and evolution were analyzed. SPSS for Windows was used for statistical analysis, applying the Mann-Whitney and Fisher's exact tests. RESULTS: A total of 23 children were admitted. The incidence was 8.2 per 100 000 children under 5. Their ages ranged from 6 months to five years (median 20 months). Half of the patients were aged < 2 years, and 21 (91%) were under 5. Most were male (74%) and white (83%). Nine children lived in the same area and ten (43%) had a concomitant infectious disease (parvovirus, Chlamydia pneumoniae, respiratory syncytial virus, enterovirus and herpesvirus 6). Twenty children had typical Kawasaki disease. Twenty-two received combined therapy with aspirin and high dose immunoglobulin, which was administered, on average, on the seventh day of the disease. Coronary disease was diagnosed in seven (30%) children. The frequency of cardiac lesions was highest in the youngest age group (< 2 years). The mean follow-up was 16 months. There was no mortality and aneurysmal changes persisted in only one patient. CONCLUSIONS: Cardiac disorders were more frequent in the youngest age group, as has been reported elsewhere. The common geographic origin and the evidence of several infectious agents suggest that infection may trigger the immunopathogenesis of KD.     

Kawasaki disease.

Kawasaki disease is a leading cause of acquired heart disease in children in the USA. An acute vasculitis of unknown etiology, it occurs predominantly in infancy and early childhood, and more rarely in teenagers. Coronary artery aneurysms or ectasia develop in approximately 15-25% of children with the disease. Treatment with intravenous gamma globulin, 2 g per kg, in the acute phase reduces this risk three- to fivefold. Angiographic resolution occurs in approximately one-half of aneurysmal arterial segments, but these show persistent histologic and functional abnormalities. The remainder continue to be aneurysmal, often with development of progressive stenosis or occlusion. The worst prognosis occurs in children with so-called 'giant aneurysms', i.e. those with a maximum diameter greater than 8 mm, because thrombosis is promoted both by sluggish blood flow within the massively dilated vascular space and by the frequent development of stenotic lesions. Serial stress tests with myocardial imaging are mandatory in the management of patients with Kawasaki disease and significant coronary artery disease to determine the need for coronary angiography and transcatheter interventions or coronary bypass surgery. Continued long-term surveillance in patients with and without detected coronary abnormalities is necessary to determine the natural history of Kawasaki disease.     

Repetitive yawning associated with cardiac tamponade

Yawning occurs frequently in daily life and is often attributed to boredom and fatigue. Rarely, it may be a symptom of serious underlying medical illness, primarily involving the central nervous system. We report a case of acute cardiac tamponade resulting from a large, malignant pericardial effusion. The patient manifested striking repetitive yawning that resolved immediately after pericardial drainage. An association between repetitive yawning and acute cardiac tamponade has not been previously described.     

Hemophilus influenzae pericarditis with cardiac tamponade

The unusual occurrence in an adult of purulent pericarditis caused by Hemophilus influenzae, type b and complicated by cardiac tamponade is described. Medical and surgical treatment was required. The clinical course and the pathologic report of tissue removed at pericardiectomy within 3 weeks after onset of the infection indicated the development of “acute” constrictive pericarditis. The patient fully recovered and was asymptomatic 3 years later without evidence of chronic constrictive pericarditis.     

Peripheral gangrene associated with Kawasaki disease.

Three American infants with Kawasaki disease (KD) complicated by peripheral extremity gangrene are reported. Eight such patients (only 1 from Japan) have been reported previously. These 11 patients, infants less than 7 months old at onset of KD, are predominantly non-Asian. At least nine had associated giant coronary aneurysms, and eight had associated peripheral arterial aneurysms. In eight infants the diagnosis of KD was not established and therapy was not instituted until greater than or equal to 14 days after onset. Peripheral ischemia initially was noted 15-31 days after onset. Although the pathogenesis of this complication is not well understood, it likely includes some combination of local peripheral arteritis, arteriospasm, thrombosis peripherally and/or more proximally (e.g., in an axillary artery aneurysm), and cardiogenic shock. Treatment may include use of antiinflammatory agents such as salicylates and intravenous gamma globulin, vasodilative agents and/or methods, and thrombolytic and/or anticoagulant agents in an attempt to prevent the potentially devastating consequences of progressive gangrene.