Today I will show a new “Meet the examiner case”, with questions and answers similar to a real presentation. You will get more images on Wednesday and the final answer on Friday.
Images belong to a 49-year-old woman with progressive chest pain and dyspnea. She mentions being hit in the chest with a surfboard three weeks ago.
4. Any of the above
What do you see?
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Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid (A)
Three days days later the patient developed mild symptoms of cardiac tamponade. Portable chest (B) shows increased size of the cardiac silhouette. Enhanced axial CT (C) is shown.
What do you think?
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Findings: PA and lateral radiographs (A-B) show what appears to be an enlarged cardiac silhouette. Of the offered options I would think first of pericardial effusion because the pulmonary vessels are small compared to the size of the heart. In cardiomyopathy I would expect engorged pulmonary vessels. Cannot exclude thymolypoma, but I would consider it very unlikely. Probably the best answer is 4. All of the above. And I would recommend a cardiac US because traumatic pericardial effusion is the most likely diagnosis.
Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid. Note the normal thickness of the pericardium (C-D, arrows)
CT also discovered healing fractures of the anterior 4th, 6th and 7th left ribs (E-G, arrows)
After drainage, the heart shadow returned to normal size (H). Three days later the patient developed fever and mild symptoms of cardiac tamponade. Portable chest showed increased size of the cardiac silhouette, despite the presence of a draining catheter (H-I, red arrows).
Enhanced CT demonstrated a moderate amount of pericardial fluid (J-K, arrows) accompanied by bilateral pleural effusions (J, red arrows). The pericardium was surgically explored and cleaned. Staphylococcus Xilosus was grown.
After appropriate antibiotic treatment the symptoms subsided. One month later the chest at discharge appeared normal (L-M).
Final diagnosis: delayed traumatic pericarditis with subsequent infection
Pericardial effusion has many causes, one of them blunt trauma. It is usually associated with other findings: pneumothorax, fractured ribs and lung contusion. Delayed pericardial effusion is a rare manifestation of previous blunt trauma.
Plain film signs of pericardial fluid are unreliable, except for visualization of posterior displacement of epicardial fat in the lateral view, which has high value (epicardial fat sign, Fig. 1). Cardiac ultrasound is the diagnostic technique of choice.
I am showing this case because of the beauty of the initial images and the iatrogenic infectious complication, which muddled the differential diagnosis.
To complete the presentation I am showing a very rare case of cardiac volvulus. It occurred secondary to surgical trauma, after removal of part of the right pericardium (Fig. 2).
I borrowed this case from an American friend a long time ago and am ashamed to confess that I don’t remember who he was. The credit is yours, friend. Many thanks.
Coronal and sagittal CT confirm the presence of a moderate amount of pericardial fluid (C-D, arrows). Note the displaced epicardial fat in the lateral view (B, red arrow).
Six hours after the intervention the patient started to deteriorate and went into shock. Portable radiograph shows displacement of the cardiac silhouette to the right (C, arrow) and complete herniation of the heart into the right hemithorax twelve hours later. (D, arrow). A second intervention confirmed a cardiac volvulus that was corrected with a pericardial patch.
Follow Dr. Pepe’s advice:
1. Delayed pericarditis after blunt trauma is rare. Should be considered when the cardiac silhouette enlarges following blunt chest trauma
2. Echocardiography is the diagnostic method of choice for diagnosing pericardial fluid
3. Plain film signs of pericardial effusion are unreliable, except for visible displaced epicardial fat in the lateral radiograph