Clinical correlates of PR-segment depression in asymptomatic patients with pericardial effusion

OBJECTIVES: The purpose of this study was to determine the clinical correlates of PR-segment depression among consecutive asymptomatic patients with pericardial effusion (PE) detected by routine echocardiography. BACKGROUND: Pericardial effusion is a relatively common finding in clinical practice, but not many studies have evaluated electrocardiographic (ECG) changes associated with the occurrence of PE. METHODS: Among 4,061 consecutive patients referred to our echocardiography laboratory, 176 asymptomatic patients had PE correlated with their clinical history and ECG findings. RESULTS: PR-segment depression was detected in 40 patients (23%). There were no significant differences in age, gender distribution or heart rate between patients with and without PR-segment depression. Fifteen post-pericardiotomy patients (33%), 19 patients (40%) with malignant disease and 6 patients (46%) with connective tissue disease had PR-segment depression, whereas no patient with heart disease (dilated cardiomyopathy, hypertensive heart disease, old myocardial infarction, valvular heart disease), renal disease or hypothyroidism had PR-segment depression, nor widespread ST-segment elevation. Among 40 patients with PR-segment depression, 8 had ST-segment elevation in the leads of epicardial derivation, 8 had upright T waves, 20 had low to inverted T waves with an isoelectric ST-segment and 4 had ST-T-wave changes due to bundle branch block. CONCLUSIONS: PR-segment depression was a relatively common ECG sign associated with clinically silent PE, and it was an ECG indicator of inflammatory pericardial involvement.     

Clinical aspects of malignant mesothelioma in Australia

Australia is currently experiencing an epidemic of malignant mesothelioma. The clinical aspects of malignant mesothelioma were investigated in 295 Australian patients as part of a national study of the disease. Most patients were male (91%), with the mean age at diagnosis being 64 years. The predominant cell type was epithelial (38%) and the majority of primary tumours arose from the pleura (94%). Mean survival was poor (17.6 months from first symptom; 11.8 months from diagnosis). Patients with a pleural primary tumour were more likely to present with dyspnoea, chest pain and cough; to have a pleural effusion diagnosed radiologically; and to have metastatic spread. Patients with a peritoneal primary tumour were more likely to present with weight loss, loss of appetite, abdominal pain and ascites; to have radiologic evidence of asbestos exposure; and to have spread along a needle track created during a diagnostic tap. A minority of patients had past thoracic conditions, or radiologic findings, specifically related to previous asbestos exposure. About one fifth of patients had no known asbestos exposure. Forty-one per cent of subjects received some form of chemotherapy, radiotherapy and/or surgery, but no formal disease staging had been documented for any patient. Proper controlled trials of secondary and tertiary treatments in malignant mesothelioma are now needed. (Aust NZ J Med 1993; 23: 19–25.)     

Primary malignant pericardial mesothelioma—a rare cause of superior vena cava thrombosis and constrictive pericarditis

Primary malignant pericardial mesothelioma (PMPM) is an extremely rare, highly lethal and often misdiagnosed tumor. We report a 60-year-old woman complaining of dry cough, shortness of breath and exertional dyspnea due to a large pericardial effusion. The pericardial fluid volume declined after pericardiocentesis; analysis of the fluid revealed malignant cells and was negative for tuberculosis. Subsequently, the patient developed a compression of the superior vena cava and pericardial constriction. The patient’s symptoms marginally improved after partial pericardiectomy, and a diagnosis of pericardial mesothelioma was made on pathology. However, her symptoms continued to aggravate, and she died 8 months after presentation. Pericardial mesothelioma should be discovered earlier to treat patients who develop repeatedly pericardial effusion after pericardiocentesis and pericardial tamponade or those develop constrictive pericarditis.     

Malignant pleural mesothelioma caused by environmental exposure to asbestos in the Southeast of Turkey: CT findings in 117 patients

BACKGROUND AND OBJECTIVES: Malignant pleural mesothelioma (MPM) is reported to be common in the southeast of Turkey, as a result of environmental asbestos exposure. The aim of this study was to evaluate the computed tomography (CT) features of MPM in patients with a history of asbestos exposure. METHODS: The CT scans of 117 patients who had a diagnosis of MPM were retrospectively evaluated. Additionally, CT findings of histologic subtypes were compared. RESULTS: The most common CT findings included pleural effusion (n = 104, 89%), pleural thickening (n = 96, 82%), mediastinal pleural involvement (n = 77, 66%) and interlobar fissural involvement (n = 62, 53%). Histologic subtype analysis was performed in 89 patients; of these, epithelial, sarcomatous and mixed types were identified in 46, 23 and 20 patients, respectively. An analysis of CT findings demonstrated that the involvement of mediastinal pleural (91%), interlobar fissure (87%) and lung parenchyma (48%) was significantly more frequent in sarcomatous type, as compared to epithelial (61% and p < 0.01; 35 and 4%, p < 0.0001, respectively) and mixed types (65% and p < 0.05; 10% and p < 0.0001; 10% and p < 0.01, respectively). Furthermore, there was a significant correlation between pericardial involvement and chest wall involvement (r = 0.42, p < 0.05) in sarcomatous type. Similarly, lymphadenopathy and parenchymal involvement (r = 0.23, p < 0.02), pericardial and chest wall involvement (r = 0.25, p < 0.01), chest wall and interlobar fissural involvement (r = 0.25, p < 0.01) were significantly correlated, when CT findings of all histologic subtypes were combined. CONCLUSIONS: These results suggest that although CT findings of MPM vary, they may provide valuable clues to the diagnosis, at least in patients with a history of asbestos exposure. In addition, the presence of extensive lesions may suggest MPM of sarcomatous subtype.     

Malignant mesothelioma: clinical and radiological description of 45 cases with and without asbestos exposure

OBJECTIVE: Our aim was to identify and describe the main symptoms, clinical presentation, and radiographic changes in malignant mesothelioma (MM) patients. MATERIAL AND METHODS: We reviewed the medical and X-ray records of all patients diagnosed with MM, admitted between 1991 and 1998 to the National Institute of Respiratory Diseases (INER), which is a governmental institution specialized in chest disease in Mexico City. The following data were collected: Age, occupation, asbestos exposure, latency, family history of cancer, clinical symptoms, and X-ray changes. Data are presented as percentages by sex and age group. RESULTS: We found 45 cases of MM; in 80% of them a history of asbestos exposure could not be documented. The 51-60 years age group had the highest frequency of MM. Dispnea and chest pain were the presenting symptoms in most patients. Pleural effusion and pleural thickening were the X-ray abnormalities observed in 75% of the patients. CONCLUSIONS: The clinical and radiographic findings among patients with MM without asbestos exposure were similar to those with a history of asbestos exposure.     

Pericardial mesothelioma: apropos of a case

We report a case of primary pericardial malignant mesothelioma in a 53-year old male with no asbestos previous exposure. The first clinical sign was a massive pericardial effusion causing hemodynamic disturbances. CT confirmed the initial ecochardiographic diagnosis. The patient underwent pericardiocentesis which improved his hemodynamic status as well as showed malignant cellularity in the liquid examination. Surgical treatment, including pericardiectomy and tumor resection, together with chemotherapy restored normal hemodynamics, the patient being now asymptomatic. We want to emphasize the rarity of this tumor and its insidious clinical presentation even leading to hemodynamic impairment, as well as the great value of echocardiography and CT in its diagnosis, although, in some cases, thoracotomy has been the only valid diagnostic procedure.     

Echocardiographic identification of mitral valvular abnormalities in patients with mixed connective tissue disease

To evaluate cardiac involvement in mixed connective tissue disease (MCTD), M-mode, 2-dimensional and pulsed Doppler echocardiography were performed in 17 patients with MCTD. Pericardial abnormalities were present in 4 patients (24%), including small pericardial effusion (less than 1 cm) in 2 patients and pericardial thickening in 2 patients. Verrucous thickening of the mitral valve was detected in 2 patients (12%) by 2-dimensional echocardiography. Pulsed Doppler echocardiography revealed the presence of mild mitral regurgitation in one of them. To our knowledge, such mitral valve abnormalities have not been reported. Future larger studies are needed in order to evaluate the incidence and natural evolution of these mitral valvular abnormalities.     

Neoplastic pericardial effusion. Efficacy and safety of intrapericardial treatment with cisplatin.

AIMS: To evaluate the clinical efficacy, safety, and long-term effect of intrapericardial treatment with cisplatin in large neoplastic pericardial effusions. METHODS AND RESULTS: Out of the registry of 260 patients undergoing pericardiocentesis, 42 patients with neoplastic pericardial effusion (69% males, mean age 58.8+/-13.2 years) were selected for treatment with cisplatin (single instillation of 30 mg.m(-2) x 24h(-1)) in addition to the tumour-specific systemic chemotherapy. All patients underwent clinical examination, echocardiography, pericardiocentesis, pericardioscopy, and epicardial biopsy. Pericardial effusion and biopsy analyses included biochemistry, cytology, serology, microbiology, histology, immunohistology, and PCR. The following malignancies were established: lung cancer, 52.4%; breast cancer, 19.0%; Hodgkin's disease, 4.8%; oesophageal cancer, 2.4%; mesothelioma, 2.4%; colon cancer, 4.8%; and undifferentiated cancer of unknown origin, 14.2%. Cisplatin appeared to prevent recurrence of pericardial effusion during the first 3 months of the follow-up in 92.8%, and after 6 months in 83.3% of the patients. Lung cancer patients had fewer effusion relapses at the 6 months follow-up (4.5%) than breast cancer patients (37.5%)(P<0.05). Myocardial ischemia occurred after 1/42 cisplatin instillations, but there were no other complications. CONCLUSION: Intrapericardial treatment with cisplatin appeared to successfully prevent recurrences of neoplastic pericardial effusion. The treatment was more successful in lung than in breast cancer patients.     

Pericardial effusion and mitral valve involvement in systemic lupus erythematosus. Echocardiographic study.

Echocardiography was used in 30 women and 2 men with systemic lupus erythematosus (SLE) in order to determine the incidence and severity of pericardial effusion and mitral valve involvement. 31 patients showed normal thickness of the mitral valve leaflets, only one patient showed irregular thickening of the leaflets suggesting the presence of vegetations. Mitral valve motions were normal in all patients. These results indicate that myocardial and valvular involvement in SLE is usually not severe enough to result in haemodynamic abnormalities. Pericardial effusion was found in 2 patients who were symptom free, whereas 4 of the patients with a past history suggestive of pericarditis showed no echocardiographic evidence of pericardial effusion. These suggest the transient nature of pericarditis in SLE, and the value of echocardiography as a diagnostic tool in detecting clinically inapparent lupus pericarditis.     

Pericardial effusion in acute myocardial infarction: clinical feature and significance]

To determine the incidence and clinical significance of pericardial effusion after acute myocardial infarction, two-dimensional echocardiography was serially performed in 137 consecutive patients. Pericardial effusion was observed in 45 patients (33%), of whom 22 were followed until they recovered and were discharged. Pericardial effusion was more frequent in patients with anterior acute infarction than those with inferior acute infarction, and so it was in non-recanalized patients than in recanalized ones. Patients with pericardial effusion had higher peak levels of creatine kinase, higher wall motion score indices, and higher defect scores of thallium imagings. The improvement of regional wall motion at an infarct zone in patients with pericardial effusion was less regardless of the successful early recanalization. These results show that pericardial effusion is a common event in patients with acute myocardial infarction and observation of transition of pericardial effusion is important for predicting prognosis.     

Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas

Ten patients were enrolled in this study to evaluate the therapeutic value of percutaneous balloon pericardiotomy in patients with symptomatic pericardial effusion secondary to malignant diseases. Four patients had breast cancer; 2 had lung cancer; 1 had non-Hodgkin's lymphoma; and 3 had malignant pleural mesothelioma, which is commonly seen in Central Anatolian region of Turkey. All patients underwent percutaneous balloon pericardiotomy with monofoil balloons (Mansfield, NuMed). No complication was seen during these procedures. In 3 patients, the balloon could not be expanded completely and was entered from a more lateral position by a second puncture. There was no recurrence of pericardial effusion in 6 of 7 patients without mesothelioma. After percutaneous balloon pericardiotomy, surgical subxiphoid windowing was performed due to drainage greater than 100 mL/day in a patient with lung cancer and in 1 patient with mesothelioma. In the other 2 patients with mesothelioma, recurrence of pericardial effusion was seen and then subxiphoid surgical windowing was performed due to development of cardiac tamponade in 1 of them. All the patients died 68.6 +/- 36 days later due to the primary malignancies. The survival time of patients with mesothelioma was shorter than that of the others (p < 0.05). These results suggest that percutaneous balloon pericardiotomy may be used in the treatment of patients with malignant pericardial effusion as an alternative to surgical pericardial window creation. But in patients with malignant pleural mesothelioma, the success rate of this procedure was lower than that of the others.     

Incidence and significance of pericardial effusion in acute myocardial infarction as determined by two-dimensional echocardiography

To determine the incidence and clinical significance of pericardial effusion after acute myocardial infarction, two-dimensional echocardiography was serially performed in 66 consecutive patients. Pericardial effusion was observed in 17 (26%); the effusion was small in 13 patients, moderate in 3 and large with signs of cardiac tamponade in 1. In this patient, two-dimensional echocardiography strongly suggested myocardial rupture. The observation of pericardial effusion was not associated with age, sex, previous myocardial infarction, atrial fibrillation or treatment with heparin. It was more often a complication of anterior than of inferior acute infarction. Patients with pericardial effusion had higher peak levels of creatine kinase and lactic dehydrogenase and a higher wall motion score index. More patients with pericardial effusion had congestive heart failure or ventricular arrhythmias, developed a ventricular aneurysm or died within 1 year after their infarction. In conclusion, pericardial effusion is frequently visualized by two-dimensional echocardiography after acute myocardial infarction and its presence is associated with an increased occurrence of complications and cardiac death.     

Respiratory malignancies induced by asbestos exposure and evaluation of cases with typical pleural malignant mesothelioma and lung cancer with asbestosis

Asbestos exposure induces lung fibrosis, i.e. asbestosis, and furthermore, pathological changes of pleura, i.e. asbestos pleurisy of pleural plaque. Generally, asbestosis is induced by massive exposure to asbestos and pleural changes are induced by low dose exposure to asbestos. The most important diseases which are induced by asbestos exposure are malignancies, especially malignant mesothelioma and lung cancer. Two cases, one malignant mesothelioma, the other lung cancer with asbestosis induced by asbestos exposure received almost the same dose of asbestos, as estimated from the period of asbestos exposure and occupational history and the same kind of asbestos (crocidolite) and had a smoking history. We do not know which elements may induce malignancies under asbestos exposure. Recently, some reports described that asbestos mediated the transformation of genes and this action induced malignancies. We should extend our study to the gene problem in cases of malignant mesothelioma and lung cancer induced by asbestos exposure.     

以心包积液为主多浆膜腔积液患者的病因学分布和临床特征分析

目的:明确以心包积液为主多浆膜腔积液患者的病因学分布以及恶性积液和非恶性积液患者临床特征的差异.方法:回顾性分析2010年1月至2017年12月于北京大学人民医院住院治疗的326例以心包积液为主多浆膜腔积液患者的临床资料,明确病因分布情况;并根据多浆膜腔积液是否为恶性肿瘤所致,分为恶性积液组和非恶性积液组,分析两组患者...     

The role of environmental and occupational exposures in Turkish immigrants with fibre-related disease.

Environmental exposure to tremolite and erionite causes endemic diseases of the lung and pleura in Turkey. This study aimed to evaluate the impact of these exposures and further occupational exposures on fibre-related diseases in Turkish immigrants living in Belgium. The study included 51 males and 17 females that emigrated < 1-38 yrs ago. Most of them (n=46) had nonmalignant pleural lesions, one had asbestosis and one had mesothelioma. Environmental asbestos exposure was likely for the majority of patients (60%), but there were also reports of possible occupational asbestos (n = 14) and erionite (n = 2) exposure. Tremolite was the main fibre type in bronchoalveolar lavage fluid (BALF). Elevated concentrations of amosite or crocidolite were detected in only two patients. The delay elapsed since the end of the environmental exposure had no influence on the asbestos body or the tremolite fibre concentrations in the BALF of Turkish immigrants. Most fibre-related diseases in Turkish immigrants are probably due to environmental rather than occupational exposure. Precise information about geographical origin and occupation should be obtained when investigating these patients. Mineralogical analysis of bronchoalveolar lavage fluid gives valuable information on the type and intensity of exposure, especially in patients with both environmental and occupational exposure.     

A case of malignant pleural mesothelioma following exposure to atomic radiation in Nagasaki

Abstract We report the case of a 75-year-old Japanese man who developed malignant mesothelioma in the left hemithorax 50 years after the dropping of the atomic bomb on Nagasaki in 1945. This may be the first reported case of malignant mesothelioma following exposure to atomic radiation. Asbestos is the leading cause of malignant mesothelioma, but radiation therapy is the primary non-asbestos-related cause. In the case of radiation therapy, the interval between exposure and the occurrence of malignant mesothelioma tends to be many years. This patient was at a high risk of malignant mesothelioma as he had been exposed to radiation from the atomic bomb and may also have had a history of asbestos exposure at the munitions factory where he was employed as a shipbuilder for 2 years. It has been suggested that combined exposure to atomic radiation and asbestos is associated with an increased incidence of malignant mesothelioma. If thickening of the pleura or pleural effusion is found in atomic bomb survivors, malignant mesothelioma should be considered as one of the options in the differential diagnosis, even although the atomic bomb attacks occurred several decades ago.     

A case of triple malignancies (gastric cancer, lung cancer and malignant pleural mesothelioma) after asbestos exposure]

This case study centers on a seventy-eight-year-old man with triple malignancies, namely, gastric cancer, lung cancer and malignant pleural mesothelioma, all of which developed at different times. The histological types were adenocarcinoma of the stomach, squamous cell carcinoma of the lung and sarcomatous malignant pleural mesothelioma. Gastric cancer was treated by endoscopic mucosal resection 2 years ago. The patient presented with a chief complaint of dyspnea, and right pleural effusion was found on chest radiography. The right-side effusion disappeared spontaneously, but a small mass on the left side was diagnosed as lung cancer, and so left inferior lobe resection was performed. Malignant pleural mesothelioma appeared after one year of pleural effusion and the patient died of mesothelioma one year after diagnosis. At autopsy, the gastric cancer and lung cancer had not relapsed and malignant pleural mesothelioma had metastasized to the lung, liver, adrenal gland and small intestine. He was a sailor by profession and it was obvious that he had been exposed to asbestos, because 538 asbestos bodies per 5 g of wet lung tissue were detected. His advanced age was one of the risk factors for the multiple malignancies, and the asbestos exposure was considered to have compounded these hazards to cause the triple malignancies. It is well known that lung cancer and malignant mesothelioma are induced by asbestos exposure, but multiple cancers including lung cancer and malignant mesothelioma are extremely rare.     

Epidemiology of pleural mesothelioma in a population with non-occupational asbestos exposure

Background and objective:   This study describes the epidemiology of malignant pleural mesothelioma (MPM) in a rural population with environmental asbestos exposure.
Methods:   Patients with diagnosed MPM were recruited and their relevant demographic and exposure data were analysed.
Results:   A total of 131 patients with MPM (59 men, 72 women) were studied. The patients' mean age was 57.8 years and the mean exposure duration was 28.9 years. The cumulative fibre count of the villagers ranged from 0.19 to 14.61 fibre/mL-years. Of the 131 patients, 85 had epithelial cell type, 20 had mixed, and eight had sarcomatous pleural mesothelioma. No significant relationship was found between asbestos fibre type and age, exposure period, or cellular type of MPM; similarly, no significant relationship could be found between the cellular type and age or exposure period. Patients with sarcomatous mesotheliomas were considerably older. Only five of 131 (3.8%) patients had a family history of mesothelioma.
Conclusions:   Environmental exposure to asbestos begins at birth and this may be important in the age of disease onset, if a threshold model for cancer initiation is operative. Both men and women had an excess risk of mesothelioma. Given that a family history of MPM was not common in this relatively homogenous patient group, a genetic predisposition to mesothelioma appears unlikely.     

A case of diffuse malignant mesothelioma of the pleura with bilateral chylothorax]

We describe a case of bilateral chylothorax with malignant pleural mesothelioma. A 41-year-old woman was admitted to our hospital because of dyspnea. She had no history of exposure to asbestos. A chest radiograph and chest computed tomogram (CT) on admission revealed massive bilateral pleural effusion and a large tumor with pleural thickening in the left lateral and anterior parts of the pleura and mediastinum. Biochemical tests of pleural fluid revealed chyle. Two years before, she had been diagnosed through histological and histochemical examinations as having diffuse malignant pleural mesothelioma of the epithelial type. Chest-tube drainage was performed, and pleurodesis was induced by the intrathoracic injection of OK-432 at 10 KE per dose. The chylothorax disappeared after pleurodesis. To date, reports of malignant mesothelioma with nontraumatic chylothorax have been rare.     

Pericardial effusion and left ventricular function in patients with acute alcoholic pancreatitis

Pericardial effusion as a complication of acute pancreatitis has been described in several isolated case reports. However, the prevalence of pericardial effusion in patients with acute pancreatitis has not been studied. Alcoholism and severe acute pancreatitis have been shown to cause left ventricular dysfunction. We studied 15 consecutive patients, hospitalized for the treatment of acute, alcohol-induced pancreatitis, and 28 control subjects by M-mode echocardiography to detect pericardial effusion and to assess left ventricular function. Seven patients (47%) with pancreatitis and three control subjects (11%) had pericardial effusion; the prevalence of pericardial effusion in patients with pancreatitis was significantly greater (Fisher's exact test) than in control subjects. There was no evidence of impairment of left ventricular function in the patients, all of whom had mild acute pancreatitis; the mean fractional systolic shortening of the left ventricle in patients was not significantly different from that of control subjects (38% +/- 8.5% vs 37% +/- 8.0%), and the mean velocity of left ventricular circumferential shortening in patients was significantly higher than in control subjects (1.58 +/- 0.34 circumferences per second vs 1.29 +/- 0.32 circumferences per second). We conclude that in patients with mild acute alcohol-induced pancreatitis, pericardial effusion occurs frequently and that left ventricular function is unimpaired.