Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain ‘idiopathic’.     

Evaluation and Management of Pericardial Effusion in Patients with Neoplastic Disease

The incidence and extent of pericardial involvement in neoplastic disease varies. In a considerable number of patients with breast or lung cancer or with mediastinal lymphoma, in addition to direct involvement by the tumor, radiation therapy as well as systemic tumor treatment can also lead to pericardial effusion. In addition, in immunosuppressed tumor patients, pericardial effusion can also arise from viral, bacterial, and autoimmune causes. To distinguish between these 3 different conditions leading to pericardial effusion, the diagnosis should be based on pericardiocentesis followed by fluid analysis for cytology and biomarkers, on epicardial and pericardial biopsy facilitated by flexible pericardioscopy with analysis of specimens by conventional histology and molecular biology techniques for viral and microbial aetiology. We collected prospectively but analyzed retrospectively 357 patients undergoing pericardiocentesis from 1988 to 2008 and identified 68 patients who had cancer-related pericardial effusion. With these methods, 42 patients demonstrated malignant effusion, 15 patients had radiation-induced pericardial, effusion, and in 11 patients without radiation therapy, the effusion could be attributed to either viral infection in 5 cases or to an autoimmune process in the remaining 6 patients. Consequently, intrapericardial treatment could be tailored for each cohort: neoplastic effusion was treated with intrapericardial cisplatin (single instillation of 30 mg/m² per 24 hours); in addition to the tumor-specific systemic chemotherapy, intrapericardial triamcinolone acetate (Volon A) was given in a dose of 500 mg/m² in the patients with autoimmune and radiation-induced effusion. Saline rinsing and intrapericardial sclerosing treatment were the treatment of choice in viral pericardial effusion. Oral colchicine treatment (2-3 × 0.5 mg) was given in all patients for at least 3 months. Recurrence of pericardial effusion was prevented for at least 3 months in more than 85% of patients. This differential diagnostic approach and the results of treatment were compared with published series.     

Treatment of Pericardial Disease

The pericardium is composed of visceral and parietal components. In view of the pericardium's simple structure, pathologic processes involving it are understandably few. However, despite a limited number of clinical syndromes, the pericardium is affected by virtually every category of disease, including infectious, neoplastic, immune—inflammatory, metabolic, iatrogenic, and traumatic. Thus, the recognition of pericardial heart disease remains challenging. Treatment of pericardial disease is also problematic in that there is a paucity of randomized, placebo‐controlled trials from which appropriate therapy may be selected and important clinical decisions assisted. This article reviews pericarditis and its sequelae, pericardial effusions, cardiac tamponade and constrictive pericarditis,     

Intrapericardial Treatment of Autoreactive Myocarditis with Triamcinolon Successful Administration in Patients with Minimal Pericardial Effusion

A major clinical drawback in the treatment of autoreactive pericarditis is its inherent feature to relapse. Intrapericardial treatment with triamcinolone was reported to be efficient in patients with large, symptomatic autoreactive pericardial effusions, avoiding side effects of systemic treatment as well as compliance problems. Intrapericardial treatment with 300 mg/m² triamcinolone was for the first time performed in patients with autoreactive myopericarditis and minimal pericardial effusions (75 to 110 ml). After 12 months of follow-up both patients are asymptomatic and there were no further recurrences of pericardial effusion. Pericardiocentesis in these patients was performed with the application of the PerDUCER^® device, guided by pericardioscopy. This device has a hemisperical cavity at the top of the instrument connected with a vacuum-producing syringe. In this cavity the pericardium is captured by vacuum and tangentially punctured by the introducer needle. Pericardium that can be captured, must be up to 2 mm thin to fit into the hemispherical cavity. Pericardioscopy performed from the anterior mediastinum significantly contributed to the success of the procedures enabling visualization of the portions of the pericardium free of adipose tissue or adhesions, suitable for puncture with the PerDUCER^®. In conclusion, intrapericardial treatment of symptomatic autoreactive myopericarditis with minimal pericardial effusion was safely and efficiently performed in 2 patients. Pericardiocentesis was enabled by means of the PerDUCER^® device, facilitated by pericardioscopy. Zusammenfassung Die Behandlung von Patienten mit autoreaktiver Perikarditis wird durch die hohe Rezidivrate kompliziert. Bisher erfolgte eine lokale intraperikardiale Behandlung mit Triamcinolon nur bei Patienten mit großen, symptomatischen Perikardergüssen, um die Nebenwirkungen einer systemischen Corticoidtherapie und die tägliche Medikamenteneinnahme zu vermeiden. Hier wird erstmals über die intraperikardiale Therapie mit 300 mg/m² Triamcinolon bei zwei Patienten mit autoreaktiver Myoperikarditis und minimalem Perikarderguss (75 bis 110 ml) berichtet. Nach zwölf Monaten sind beide Patienten asymptomatisch und ohne Perikardergussrezidiv. Bei beiden Patienten wurde die Perikardpunktion mit dem neuen PerDUCER^®-System unter perikardioskopischer Sicht durchgeführt. Dieses System verfügt über einen halbkugelförmigen Hohlraum an der Spitze, der mit einer Vakuumspritze verbunden ist. In dem halbkugelförmigen Hohlraum wurde das parietale Perikard durch das Vakuum angesaugt und fixiert und konnte anschließend durch eine aus dem Hohlkörper auszufahrende Nadel punktiert werden. Die Punktion mit dem PerDUCER^® wetzt voraus, dass die Dicke des Perikards 2 mm unterschreitet. Die mediastinale Perikardioskopie trug bei beiden Patienten wesentlich zum Erfolg der Prozedur bei, weil sie die Auswahl einer Perikardoberfläche ohne Adhäsionen und Fettgewebe erlaubte. Damit konnte erstmals eine intraperikardiale Behandlung mit Triamcinolon bei zwei Patienten mit einer symptomatischen autoreaktiven Myoperikarditis und einem kleinen (< 110 ml) Perikarderguss unter simultaner Verwendung von mediastinaler Perikardioskopie und PerDUCER^®-Punktionssystem dokumentiert werden.     

超声心动图监测经皮介入诊断治疗心包积液

目的：原因不明心包积液是临床诊断治疗的难题。本文旨在探讨超声心动图监测下经皮心包多部位活检、引流、灌洗诊断治疗此病的效果。方法：８０例病人在超声心动图监测下经皮穿刺用塞林格技术放入止血鞘，通过鞘内用活检镜行多部位心包活检。标本经病理常规及免疫组化（Ｋｅｒａｔｉｎ法）在光镜及电镜下检查经病因学包括多聚酶链反应（ＰＣＲ）查出病因。经鞘内用猪尾导管引流出所有积液，进行３～１４天病因灌洗治疗，然后拔出导管。结果：病因诊断率达８６％以上，经３～６个月随访，治愈率达９０％，无明显并发症发生。结论：新方法将介入技术应用于心包积液，集诊断、治疗于一体，较以往心包穿刺等方法有明显优越性。此法安全，适用于各级医院推广应用，国内外尚无同类方法报道。     

An Unusual Presentation of Adult-Onset Still's Disease in a Patient with Recurrent Pleural and Pericardial Effusions

Adult-Onset Still's Disease (AOSD) usually presents with a salmon-colored skin rash and arthralgias. However, it can also be present with pleural and pericardial effusions. These effusions are often misdiagnosed as having an infectious etiology because AOSD usually present with fever, leukocytosis, elevated inflammatory markers, procalcitonin and CRP. There is usually a delay in giving steroids until the exclusion of all infectious etiologies, including extensive workups. Herein, we present a case report of AOSD in a patient with recurrent pleural and pericardial effusions, with no skin rashes or joint pain. Patient initially presented with fever, pleural and pericardial effusions, which was then treated as pneumonia with parapneumonic effusions. Patient returned for the second time with shortness of breath, productive cough, and fever, with no resolutions of pleural and pericardial effusions. Patient was found to have an extremely high ferritin levels, whereby a diagnosis of AOSD was made after excluding infection, malignancy and other rheumatological disorders based on the Yamaguchi criteria. AOSD is a rare disease with unusual presentation and diagnosis is often delayed. This case aimed to raise awareness among physicians of the multifaceted presentation of AOSD.     

Intrapericardial pheochromocytoma

A patient with intrapericardial pheochromocytoma is described, and the literature on this subject is reviewed. Iodine 131-labeled metaiodobenzylguanidine scintigraphy was superior to computed tomography in localizing the tumor. This newly introduced method is safe, specific, noninvasive, and may prove to be the method of choice for localizing pheochromocytomas. The patient was prepared for surgery with alpha- and beta-adrenoceptor blocking agents. The tumor was markedly adherent to the posterior wall of the left and right atria. Cardiopulmonary bypass was used to allow excision of the tumor. Hemostasis was attained with difficulty due to marked vascularity of the tumor.     

Intrapericardial pheochromocytoma

Pheochromocytoma is a catecholamine-secreting tumor. Most cases are intra-adrenal, and intrapericardial pheochromocytomas are extremely rare. We report a case of a 30-year-old woman with a seven-year history of hypertension. The concentration of blood noradrenaline was found to be elevated. Chest computed tomography scan showed a limited bulge in the superior border of the right atrium. Magnetic resonance imaging confirmed the existence of a tumor. Coronary arteriography detected a mass near the right atrium, which was nourished by an aberrant branch of the right coronary artery. After preoperative preparation, the patient underwent pericardial tumor resection. Postoperative recovery was uneventful and the patient was successfully discharged 20 days later.     

血管镜直视经皮心包活检引流灌洗治疗心包积液

目的评价经皮血管镜直机心包活检引流灌洗术对心包积液的病因诊断、治疗、近期疗效随访结果。方法通过超声监测下经皮穿刺心包腔后用赛林格技术放入止血鞘，经鞘内放入血管镜目镜检查并改良技术在直视下活检取得标本，经用分子生物学，免疫组化等系列病理，病因检查确诊。经引流缓解心包填塞后进行病因针对性灌洗治疗。结果经临床160例应用病因诊断率达90％，恶性积液确诊率达93％，使心包积液近期治愈率达90％左右。结论此方法集诊断治疗一次完成。安全可靠，无严重的并发症。较以往方法有明显提高了诊疗效果。     

心脏包虫病的外科治疗

目的:总结心脏包虫病的临床特点及外科手术治疗的经验。方法:回顾性分析我院在1978-02至2009-10手术治疗的21例心脏包虫病患者的临床资料。其中男13例,女8例;年龄8～46(30.0±9.5)岁。有症状者16例,无症状5例。体检阳性者11例,阴性10例。包虫免疫试验阳性17例,阴性4例。21例患者均行X线胸片、心电图、超声心动图检查,4例行计算机断层摄影术(CT)检查。全麻非体外循环下行心脏包虫病手术19例,体外循环下手术2例。术后对生存者进行随访,随访时间5～168个月,平均(86±14)个月。结果:所有患者术后恢复顺利,围手术期无死亡。随访期间死亡1例,总死亡率为4.8%;复发3例,复发间隔8～15个月,总复发率为14.3%。结论:多普勒超声心动图对心脏包虫病有重要的诊断意义,外科手术是心脏包虫病的首选治疗措施,内囊摘除术可取得较好的效果。