Chest Pain, Short Of Breath

Hx: A 55 yo female presents by EMS complaining of chest pain. She states she was about to begin eating lunch at a restaurant when she had sudden onset of mid sternal chest pressure radiating to the back. She has associated shortness of breath, which has been present for the past 4 days and gradually worsening. She also states that she can not lay flat because the shortness of breath is worse in that position, and taking deep breaths increases the chest pain. There is no pain radiation to the neck, jaw, or arms. She denies any cough, fever, recent illnesses, or history of similar symptoms. She also denies recent travel, leg pains or injury, prolonged immobilization, or any history of PE/DVT.

ROS: negative except as listed above.

PMHx:

  • Rheumatoid arthritis – states previously on prednisone, now only on tramadol prn joint pain.
  • CHF – she notes an admission one year ago when she was told she had congestive heart failure. She states she takes no meds for it, has no history of hypertension, and denies any coronary disease.

SocHx:

  • Occasional cigarettes
  • No alcohol
  • No drugs

Fam Hx: none

Exam:

  • Vital Signs- Pulse 130 , BP 123/77, Temp 98.1, RR 22
  • General- anxious and in moderate distress due to shortness of breath.
  • Skin- dry, no rashes
  • HEENT- normal
  • Lungs- clear, tachypniec, shallow respirations
  • Cardiovascular- tachycardia, regular, no murmurs, pulses equal all extremities, no edema.
  • Abdomen- soft, non-tender, non-distended, difficult to assess fully because she can not lay flat
  • Extremities – normal
  • Neurological – normal

Differential:

  • ACS
  • PE
  • Pulmonary Edema/CHF
  • Aortic Dissection
  • Thyrotoxicosis
  • Cocaine Abuse
  • Pneumonia / sepsis
  • Pericarditis

Diagnostics:

  • EKG- sinus tachycardia, rate 130, no ST elevation, normal PR.
  • CBC/CMP/Trop normal
  • D-Dimer 16 (nl < 0.5, ug FEU/ml)
  • CXR (see image) demonstrated clear lung fields but significant cardiomegaly. A comparison film from one year prior was found.IMG_3886.JPG
  • CT Pulmonary Angiogram (see images) showed no PE or DVT but did provide the answer
    IMG_3887.JPG

    Heart border (red), pericardial sac border (green), effusion (yellow arrow)

    IMG_3888.JPG

    Heart border (red), pericardial border (green), effusion (yellow arrow)

  • Echocardiogram (see video) showed a significant pericardial effusion with septations (fibrous bands) and a mild component of tamponade. 

     

Hospital Course: Emergent consultation with thoracic surgery was obtained. The patient was taken to the operating room for a pericardial window and a peri-operative TEE noted increasing ventricular collapse. Approximately 500cc bloody fluid was removed and a pericardial drain was placed. Fluid analysis demonstrated bloody fluid, 62% segs, 2% eos, 34% lymphs, 2% monos, 0% baso, glucose 62 (serum 94), ldh 872, protein 7.2 g/dl (serum TP 8.3), ph 7.422, and specific gravity > 1.035. No malignant cells were seen in fluid. AFB and fungal stains and cultures were negative. Standard pericardial fluid cultures were also negative. Pericardial biopsy samples showed only fibrinous pericarditis.
Additional inpatient lab testing demonstrated an elevated CRP 18.1 md/dl and ESR > 120 mm/hr. However, her rheumatoid arthritis factor was undetectable and her cyclic citrul peptide IgG antibody was negative. In addition her brain natriuretic peptide (BNP) was normal,  TSH was normal, HIV was negative, and ANA screen negative. She did receive a drug screen which was also negative.
The patient had an uncomplicated hospital course and was discharged symptom free with primary care follow up to continue further evaluation. No specific etiology for the effusion was identified.

Discussion: Pericardial effusion is an accumulation of fluid within the pericardial sac. Up to 50 mL can be normal and the sac can hold up to 200 mL acutely or up to 2 L when accumulating slowly. Typically symptoms are caused by mass effect of the fluid on surrounding structures (stomach, lung, phrenic nerve and heart). These can range in presentation from chest pain, shortness of breath, nausea, and epigastric pain, to hiccups. Classical teaching states that larger effusions may demonstrate muffled heart sounds, distended neck veins and hypotension (Beck’s triad). EKG findings may show low voltage or electrical alternans and chest X-ray may demonstrate a large cardiac silouhette if there is more than 250 mL of fluid. The diagnosis is typically confirmed by echocardiography which allows for the evaluation of tamponade physiology. Tamponade results when atrial and eventually ventricular diastolic collapse occurs as a result of mass effect, typically seen in the right heart.
Although pericarditis and pericardial effusions are not rare, the vast majority of cases are idiopathic with no discernible cause identified. Fluid analysis can be helpful in differentiating exudate versus transudate, and cultures are typically obtained as well. Additionally, serum testing is guided by the suspicion for underlying cause based on history.
In this case, the patient’s presentation included only chest pain, dyspnea, and persistent tachycardia. However, her chest X-ray was suspicious and the CT confirmed the diagnosis. An echo did provide the necessary tamponade finding of mild right atrial and ventricular collapse during diastole. The patient relayed a history of CHF and RA which ultimately appears to have been erroneous. Her post op echo did not show signs of CHF or left ventricular dysfunction and her testing for rheumatoid factor and cyclic citrul peptide IgG (an RA marker) was negative. However, her case does demonstrate the often circuitous route through which ED patients arrive at a final diagnosis and the need to maintain a wide differential when evaluating the undifferentiated chest pain patient.

Further Reading:

Cleveland Clinic summary
Up-To-Date Summary

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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