A 56-year-old woman presented at our emergency clinic with dyspnea. She had a history of lung carcinoma, which was diagnosed 2 weeks ago. She was advised chemotherapy, but she did not start the treatment. Her blood pressure, heart rate, respiration rate, and oxygen saturation were 95/55 mm Hg, 103 beats/min, 18 breaths/min, and 92%, respectively. Her physical examination revealed decreased breath sound at bases and decreased heart sounds. ECG showed sinus tachycardia. Chest X-ray revealed enlarged cardiac silhouette, blunted costophrenic sinuses, and consolidation of the left lung (Fig. 1). Echocardiography demonstrated massive pericardial effusion causing tamponade (Fig. 2A). Percutaneous drainage via subxiphoid puncture was attempted. After several failed punctures, a thick and white fluid was aspirated (Video 1). After confirmation of the intrapericardial position using agitated saline, a 6F sheath was placed (Fig. 2B), and 300 mL of fluid was drained (Fig. 2C). Biochemical evaluation of the fluid revealed that the triglyceride level was above the highest limit. The patient was hemodynamically and clinically stable during 3 days of hospitalization. Ten days after discharge, the patient was readmitted to the emergency department due to dyspnea. Echocardiography showed pericardial effusion and tamponade. The cardiac team decided to perform a pericardial window (subxiphoid pericardiostomy). Surgery revealed a thickened pericardium and serous effusion (Fig. 2D and E). The patient died 2 months after the procedure due to pneumonia. Chylous pericardial effusion is the rarest cause of fluids causing tamponade. It usually occurs after surgery or trauma due to thoracic duct injury. In our case, we believe that the invasion of carcinoma in the thoracic duct or small lymphatic channels of the pericardium caused chylous effusion.
Figure 1.
PA chest X-ray showed enlarged cardiac silhouette, blunted costophrenic sinuses, and consolidation of the left lung
Figure 2.
(a) Transthoracic echocardiography (subcostal view) showed massive pericardial effusion. (b) A 6F sheath was placed into the pericardial cavity via the subxiphoid approach. (c) A total of 300 mL of chylous effusion was drained. (d) 3x2 cm of thickened pericardium was excised during subxiphoid pericardiostomy. (e) Serous effusion was drained during subxiphoid pericardiostomy
Video 1
A thick and white fluid was aspirated during puncture.
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