Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

Diagnosing the Unrecognized Systemic Absorption of Intra-Articular and Epidural Steroid Injections

ObjectiveTo present a case series of patients who were misdiagnosed with endocrine disorders because of failure to recognize the systemic absorption of intra-articular and epidural steroids and to discuss the utility of performing a urine screen to detect synthetic glucocorticoids.MethodsIn this case series, we describe the clinical, laboratory, and imaging findings of 3 patients referred to our clinic, each with a presumed endocrine disorder.ResultsPatient 1 was a 54-year-old woman with weakness, loss of appetite, and a hormonal profile suggestive of hypopituitarism. Patient 2 was a 49-year-old woman with chronic fatigue and history of physical abuse, whose history and test results were compatible with growth hormone deficiency secondary to head trauma. Patient 3 was a 46-year-old woman who was diagnosed with endogenous Cushing syndrome despite normal 24-hour urinary cortisol excretion. In each case, we subsequently elicited a history of intra-articular or epidural glucocorticoid injections, and a urine screen documented the presence of synthetic glucocorticoids. Systemic absorption of the injected steroids was thus determined to be the cause of the symptoms and abnormal laboratory findings in each case.ConclusionsThe potential for harm from intra-articular and epidural glucocorticoid administration is underrecognized by physicians, leading to expensive investigation, false diagnoses, and unnecessary treatment. A urine screen for synthetic glucocorticoids is a valuable adjunct towards appropriate diagnosis. (Endocr Pract. 2009;15:225-228)     

Multiple Disease Associations in Autoimmune Polyglandular Syndrome Type II

ObjectiveAutoimmune polyglandular syndrome type II (APS II) is characterized by adrenal insufficiency (Addison’s disease), autoimmune thyroid disease, and/or type 1 diabetes mellitus (DM1). Multiple other autoimmune diseases have been associated with APS II. Here we report a case of a patient with APS II who over the course of 10 years developed Addison’s disease, hypothyroidism, DM1, Hashimoto’s encephalopathy, vitiligo, celiac disease, seronegative arthritis, and ulcerative colitis. This is a particularly aggressive course of APS II, and this combination of autoimmune diseases has not been previously reported.MethodsA 25-year-old female with a history of ulcerative colitis (UC), celiac disease, and DM1 presented to our institution with mental status changes. She was diagnosed with Hashimoto’s encephalopathy and treated with high-dose steroids and intravenous immunoglobulin (IVIG). She recovered well from her encephalopathy but her posthospitalization course was complicated due to the development of Addison’s disease, vitiligo, seronegative arthritis, and hypothyroidism.ResultsThe current understanding of APS II and its autoimmune disease associations are briefly summarized.Submitted for publication April 10, 2014 Accepted for publication July 10, 2014 The association of UC and Hashimoto’s encephalopathy with APS II is novel and discussed in detail.ConclusionA case of a patient with APS II with a dramatic development of 8 autoimmune diseases over 10 years is described. The novel APS II developments of Hashimoto’s encephalopathy and UC are discussed. This case highlights the potential complexity and severity of the clinical course of APS II. (Endocr Pract. 2014;20:e250-e255)     

A Case of Nonischemic Cardiomyopathy Associated with Autoimmune Polyglandular Syndrome Type III

Objective:To report a case of nonischemic dilated cardiomyopathy associated with autoimmune polyglandular syndrome (APS) type III.MethodsA review of our patient’s medical records was undertaken, and her clinical history, investigations, and outcome are described. In addition, a literature review of nonischemic dilated cardiomyopathy occurring in association with autoimmune polyendocrinopathies was performed.ResultsAPS is diagnosed once a patient has developed at least 2 organ specific autoimmune diseases. APS III involves a combination of autoimmune diabetes and Graves’ disease without adrenal insufficiency. Autoimmune cardiomyopathies are not described as a feature of this condition; however, there are a few reported cases of patients with autoimmune polyendocrinopathies developing a nonischemic dilated cardiomyopathy. In this case, a 30-year-old female developed vitiligo, Graves’ disease, and latent autoimmune diabetes of the adult (LADA) over a 5-year period before presenting with conscious ventricular tachycardia (VT). This evolved into acute severe biventricular failure within a few weeks, which failed to resolve after adequate treatment of her other autoimmune conditions.ConclusionAlthough nonischemic cardiomyopathies have been associated with APS in a few published cases, this is the first case to our knowledge in a patient with APS III. (Endocr Pract. 2014;20:e183-e186)     

Conservative and surgical treatment of pericarditis--our experience

Methods and results of both conservative and invasive therapy of pericarditis were analysed in the group of 30 patients. An emphasis was on successful treatment of mild (idiopathic) pericarditis and efficiency of the early started, combined pharmacotherapy (tuberculostatics + corticosteroids) of pericarditis of tuberculous etiology. A stress is on marked immediate efficacy of surgery in case of cardiac tamponade, independent on its etiology, with simultaneous recommendation of ultrasound-guided pericardial sac paracentesis. Survival rate in patients with malignant pericarditis is relatively low.     

Early recognition of cardiac tamponade.

Nine patients with cardiac tamponade were seen in an 11-month period. Analysis of the clinical and laboratory data indicated that pulsus paradoxus was the most useful physical sign and echocardiography the most useful investigative technique. Three of nine patients died but in only one was the late recognition of tamponade a possible factor in the outcome. Pericardial fenestrations were required in four patients. Viral pericarditis accounted for the tamponade in three cases. There were two cases each of uremia and malignant disease and one case of tuberculous pericarditis. One other case followed pericardiectomy. In five patients tamponade was the initial manifestation of illness.     

Influence of involvement of anterior leaflet versus posterior leaflet on residual regurgitation as assessed by transesophageal echocardiography in patients undergoing valve repair for mitral regurgitation due to mitral valve prolapse

Cardiac tamponade is the phenomenon of hemodynamic compromise caused by a pericardial effusion. Following a myocardial infarction, the most common causes of pericardial fluid include early pericarditis, Dressler's syndrome, and hemopericardium secondary to a free wall rupture. On transthoracic echocardiography, pericardial fluid appears as an echo-free space in between the visceral and parietal layers of the pericardium. Pericardial fat has a similar appearance on echocardiography and it may be difficult to discern the two entities. We present a case of a post-MI patient demonstrating pseudo tamponade physiology in the setting of excessive pericardial fat.     

Characterization of IL-2-activated TILs and their use in intrapericardial immunotherapy in malignant pericardial effusion

Pericardial effusion (PE) and cardiac tamponade caused by malignant pericarditis are critical conditions in cancer patients, which still lack a recommended protocol for their long-term management. Percutaneous pericardiocentesis and simple drainage are commonly performed as the initial treatment. The aims of this study were to investigate the presence of cytotoxic T lymphocytes (CTLs) in malignant PE and to determine the clinical response to administering autologous tumor-infiltrating lymphocytes (TILs) into the pericardial cavity. Initially, we identified human lymphocyte antigen class-I-restricted and tumor-specific CTLs within the interleukin-2 (IL-2)-activated TILs in PEs from four patients, on the basis of interferon-γ production and lactate dehydrogenase-release assays. Clinically we observed favorable responses to the pericardial transfer of IL-2-activated autologous TILs in four patients: one male with advanced esophageal cancer, one female with recurrent lung cancer and two females with recurrent breast cancer, respectively. Autologous TILs from PEs were expanded in vitro with IL-2, characterized for CD3, CD4 and CD8 markers, checked for contamination and then infused into the patient’s pericardial space through a catheter. This was repeated biweekly. After treatment, there were no signs of recurrence of PE in either case, as determined by radiography, echocardiography and computed tomography. The only adverse effects seen were grade 1 fevers. These results suggested that intrapericardial cellular immunotherapy with autologous TILs could be a safe and effective treatment for controlling malignant pericarditis with associated cardiac tamponade, and that tumor-specific CTLs present in malignant PE might be important for tumor rejection.     

Erlotinib-Associated Exacerbation of Hypothyroidism with Pericardial Tamponade

ObjectiveTo report a case of erlotinib-associated exacerbation of hypothyroidism complicated by pericardial tamponade.MethodsWe describe the patient’s clinical presentation, biochemical workup, and clinical course.ResultsNon-small cell lung cancer was diagnosed in a 54-year-old woman. After cisplatin and radiation therapy, she was noted to have subclinical hypothyroidism that did not necessitate treatment. The tyrosine kinase inhibitor erlotinib, 150 mg once daily, was prescribed. Three months later, the patient was documented to have severe hypothyroidism. Levothyroxine was prescribed, but she continued to experience shortness of breath, fatigue, and chest and back pain, which resulted in an emergency department visit. Inpatient workup revealed cardiac tamponade with a large pericardial effusion and a right ventricular diastolic collapse. Pericardiocentesis was performed.ConclusionsThis is the first case report linking erlotinib use and thyroid disease. (Endocr Pract. 2012; 18:e111-e113)     

Bilious pericardial effusion at initial presentation in a patient with lung cancer

Background  

Cardiac tamponade as the initial manifestation of metastatic cancer is a rare clinical entity. Furthermore, a thoraco-biliary fistula is another rare complication of echinococcosis due to rupture of hydatid cysts located at the upper surface of the liver to the pleural or pericardial cavity. We report a case of non-small cell lung cancer with a coexisting hepatic hydatid cyst presenting as a bilious pericardial effusion.     

Efficacy and safety of leadless pacemaker: A systematic review,pooled analysis and meta-analysis

BackgroundLeadless pacemakers have been designed as an alternative to transvenous systems which avoid some of the complications associated with transvenous devices. We aim to perform a systematic review of the literature to report the safety and efficacy findings of leadless pacemakers.MethodsWe searched MEDLINE and EMBASE to identify studies reporting the safety, efficacy and outcomes of patients implanted with a leadless pacemaker. The pooled rate of adverse events was determined and random-effects meta-analysis was performed to compare rates of adverse outcomes for leadless compared to transvenous pacemakers.ResultsA total of 18 studies were included with 2496 patients implanted with a leadless pacemaker and success rates range between 95.5 and 100%. The device or procedure related death rate was 0.3% while any complication and pericardial tamponade occurred in 3.1% and 1.4% of patients, respectively. Other complications such as pericardial effusion, device dislodgement, device revision, device malfunction, access site complications and infection occurred in less than 1% of patients. Meta-analysis of four studies suggests that there was no difference in hematoma (RR 0.67 95%CI 0.21–2.18, 3 studies), pericardial effusion (RR 0.59 95%CI 0.15–2.25, 3 studies), device dislocation (RR 0.33 95%CI 0.06–1.74, 3 studies), any complication (RR 0.44 95%CI 0.17–1.09, 4 studies) and death (RR 0.45 95%CI 0.15–1.35, 2 studies) comparing patients who received leadless and transvenous pacemakers.ConclusionLeadless pacemakers are safe and effective for patients who have an indication for single chamber ventricular pacing and the findings appear to be comparable to transvenous pacemakers.     

"Floating arm" injury in a child with fractures of the proximal and distal parts of the humerus: a case report

Introduction

Primary malignant pericardial mesothelioma is a very rare pericardial tumor of unknown etiology.

Case presentation

A 61-year-old Caucasian woman was admitted to our hospital complaining of exertional dyspnea due to a large pericardial effusion. Intrapericardial fluid volume declined after repeated pericardiocentesis, but the patient progressively developed a hemodynamically relevant pericardial constriction. Pericardiectomy revealed a pericardial mesothelioma. Subsequently, four cycles of chemotherapy (dosage according to recently published trials) were administered. The patient remained asymptomatic, and there was no recurrence of the tumor after three years.

Conclusion

Pericardial mesothelioma should be considered and managed appropriately in non-responders to pericardiocentesis, and in patients who develop constrictive pericarditis late in their clinical course.     

Intra-pericardial thrombin injection as bailout strategy in iatrogenic pericardial tamponade

BackgroundCardiac tamponade is a rare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and sometimes haemodynamic stabilisation is difficult to achieve. Intra-pericardial thrombin injection after pericardiocentesis promotes haemostasis and acts as a sealing agent, as previously described for left ventricular free-wall rupture. We aimed to evaluate intra-pericardial thrombin injection as a bailout strategy for pericardial tamponade following percutaneous cardiac interventions.MethodsIn a 5-year single-centre retrospective analysis we identified 31 patients with cardiac tamponade due to percutaneous intracardiac procedures. Intra-pericardial thrombin injection as a bailout strategy was administered in 5 of 31 patients (16.1%).ResultsPatients receiving intra-pericardial thrombin were in a more critical state when thrombin was applied, as demonstrated by a higher rate of resuscitation (40% versus 26.9%) and a trend toward a prolonged stay in the intensive care unit (177.6 ± 84.0 vs 98.0 ± 31.4 h). None of the patients with pericardial tamponades treated with intra-pericardial thrombin needed cardiothoracic surgery. Mortality after 30 days was lower with intra-pericardial thrombin injection than with standard treatment (0% vs 15.4%). We observed no complications using intra-pericardial thrombin.ConclusionIntra-pericardial thrombin injection could be considered as a bailout strategy for patients with iatrogenic pericardial tamponade due to percutaneous procedures. We recommend further evaluation of this technique in the clinical management of refractory pericardial tamponade.Supplementary InformationThe online version of this article (10.1007/s12471-022-01701-y) contains supplementary material, which is available to authorized users.     

Silent Thyroiditis,Isolated Corticotropin Deficiency,and Alopecia Universalis in a Patient With Ulcerative Colitis and Elevated Levels of Plasma Factor VIII: An Unusual Case of Autoimmune Polyglandular Syndrome Type 3

ObjectiveTo describe an unusual case of autoimmune polyglandular syndrome (APS) type 3 and provide a brief review of the literature.MethodsWe present the clinical course and laboratory data of a patient with silent thyroiditis, isolated corticotropin (adrenocorticotropic hormone or ACTH) deficiency, alopecia universalis, and ulcerative colitis with an associated hypercoagulable state. The related literature is also reviewed briefly.ResultsA 43-year-old man who had a history of ulcerative colitis with an associated hypercoagulable state and alopecia universalis was referred to the endocrinology department for evaluation of fatigue and a mildly elevated level of thyrotropin (thyroid-stimulating hormone or TSH). He previously had mildly increased TSH levels, for which low-dose levothyroxine therapy had been prescribed. During use of this therapy, a suppressed TSH level developed, necessitating discontinuation of thyroid hormone therapy; a subsequent increase in TSH value was followed by a spontaneous return to euthyroidism. An ACTH stimulation test revealed adrenal insufficiency. His ACTH level was low, 21-hydroxylase antibodies were not present, and further testing demonstrated otherwise intact pituitary function. Magnetic resonance imaging of his pituitary gland showed normal findings. Treatment with hydrocortisone promptly decreased his fatigue. He was found to have an elevated factor VIII level as the cause of his hypercoagulable state. The patient continues to feel well with use of hydrocortisone therapy and has normal thyroid function.ConclusionThis patient’s components of APS type 3 have not been previously reported; thus, the complex nature of the APS variants is supported. (Endocr Pract. 2009;15:138-142)     

HLA-DQA1*0301-associated susceptibility for autoimmune polyglandular syndrome type II and III.

No significant differences were reported for the frequency of DR3-DQ2 and DR4-DQ8 haplotypes in a recent study of one of the largest cohorts worldwide of patients with isolated Addison's disease compared to patients with APS II. However, previous studies had suggested that the HLA-DQ genes, especially DQA1*0102, may be a genetic marker for resistance to autoimmune thyroid disease, which is the most frequent disease in APS II or III. Until now, HLA-DQA1 alleles have not been systematically investigated in APS. We determined the HLA-DR and HLA-DQA1 association in 112 unrelated patients with APS II (n = 29), APS III (n = 83) and 184 unrelated patients with single-component diseases without further manifestations of APS: Graves' disease (n = 70), Hashimoto's thyroiditis (n = 53), autoimmune Addison's disease (n = 15), vitiligo (n = 16) and alopecia (n = 30), and 72 healthy controls - German Caucasians - to identify possible predisposing and protective HLA class II alleles in APS. In agreement with previous studies, we detected a significantly higher frequency of DR 3 and/or DR 4 in patients with APS II and III compared to controls. In patients with APS II, we detected a significantly higher frequency of DQA1*0301 and *0501 compared to controls confirming the increased frequency of an extended HLA DRB1-*04-DQA1-*03-DQB-*03 haplotype as previously described. In contrast, only DQA1*0301 was increased in our patients with APS III compared to controls. Moreover, we detected an increased frequency of DQA1*0301 in patients with APS, whereas DQA1*0301 was only significantly elevated in alopecia in patients with single-component diseases without APS. Therefore, our results indicate an association between DQA1*0301 and APS II or III since this allele was otherwise not significantly associated with any of its component diseases except alopecia. Moreover, our data imply that the allele DQA1*0301 is a marker of increased risk for further APS manifestations in patients who suffer from an organ-specific autoimmune disease.     

OPERATIONS ON THE PERICARDIUM—A Review of Current Surgical Procedures

Improved management of pericardial disease has resulted from a better understanding of the pathological physiology and refined surgical technique.In acute cardiac tamponade from trauma, our experience has shown that simple pericardial aspiration, because it relieves the tamponade, renders open operation unnecessary unless the hemorrhage is unusually severe. However, in chronic tamponade, from prolonged pericardial bleeding or effusion, the “pericardio-pleural window” operation described in this article will safely decompress the pericardium without secondary infection and the necessity of reoperation. With chronic constrictive pericarditis, on the other hand, catheterization studies reveal that left heart constriction is more important than that of the right heart or vena cavae. So it is important to pay more attention to decortication of the left heart than was formerly believed.Excision of pericardial tumors, most often cystic, is indicated because they are indistinguishable from malignant growths, although they in themselves are not of serious import.Fatty and fibrous pericardium have proved to be suitable viable material for various plastic operations on the heart, lung and esophagus. Finally, experience with poudrage to revascularize the myocardium is proving that this is a very satisfactory technique which can be performed with minimal risk.     

Purulent pericarditis,an uncommon entity in modern practice: a case report

We report an 82-year-old female with pneumococcal pneumonia. Antimicrobial therapy was started in an early stage of the disease. On the 10th day of admission she developed peripheral pitting oedema with elevated jugular venous pressure and a drop in blood pressure. Her electrocardiogram showed sinus tachycardia and concave upward ST-segment elevation in almost all leads. A transthoracic two-dimensional echocardiogram revealed a large circumferential pericardial effusion, with diastolic collapse of the right atrium and a mitral inflow pattern that suggested cardiac tamponade. Emergency pericardiocentesis was performed, releasing 600 cc of thick green purulent material, followed by good haemodynamic recovery. The haemodynamic state, pneumonic infiltrate and inflammatory parameters responded gradually to antimicrobial therapy and the patient recovered and was discharged after six weeks. We conclude that even susceptible strains of Streptococcus pneumonia in a patient with no predisposing factors may still cause purulent pericarditis, even in the era of adequate antibiotic therapy.     

Surgical properties and survival of a pericardial window via left minithoracotomy for benign and malignant pericardial tamponade in cancer patients

ABSTRACT: BACKGROUND: Surgical drainage is a rapid and effective treatment for pericardial tamponade in cancer patients. We aimed to investigate the effectiveness of pericardial window formation via minithoracotomy for treating pericardial tamponade in cancer patients, and to evaluate clinical factors affecting long-term survival. METHODS: Records of 53 cancer patients with pericardial tamponade treated by pericardial window formation between 2002 and 2008 were examined. Five patients were excluded due to insufficient data. Kaplan-Meier and Cox regression analysis were used for analysis. RESULTS: Forty-eight patients (64.7% male), with a mean age of 55.20 +/- 12.97 years were included. Patients were followed up until the last control visit or death. There was no surgery-related mortality and the 30-day mortality rate was 8.33%; all died during postoperative hospitalization. Morbidity rate was 18.75%. Symptomatic recurrence rate was 2.08%. Cancer type and nature of the pericardial effusion were the major factors determining long-term survival (P <0.001 and P <0.004, respectively). Overall median survival was 10.41 +/- 1.79 months. One- and 2-year survival rates were 45 +/- 7% and 18 +/- 5%, respectively. CONCLUSION: Pericardial window creation via minithoracotomy was proven to be a safe and effective approach in surgical treatment of pericardial tamponade in cancer patients. Cancer type and nature of pericardial effusion were the main factors affecting long-term survival.     

Malignant pericardial effusion and cardiac tamponade

Cardiac tamponade due to malignant effusion, though rarely the initial manifestation of malignancy, is usually secondary to adenocarcinoma of the lung. Two cases are reported. One patient presented with cardiac tamponade; the other had diffuse cutaneous involvement of the left neck and shoulder two months before he presented with cardiac tamponade. Cytologic examination of both fluids revealed adenocarcinoma. Ultrastructural examination showed poorly differentiated adenocarcinoma in the first patient and bronchioloalveolar carcinoma in the second; carcinoembryonic antigen levels in the fluids were 9.4 ng/mL and over 60 ng/mL, respectively. The computed tomographic (CT) scans of both patients revealed mediastinal fullness with no lung involvement. Even in the absence of a pulmonary mass, lung carcinoma may be the likely primary in patients with malignant pericardial effusions.     

Granulomatous Adenohypophysitis after Interferon and Ribavirin Therapy

ObjectiveTo describe a case of granulomatous hypophysitis occurring after treatment with interferon alfa-2b and ribavirin for hepatitis C.MethodsClinical, radiologic, laboratory, and pathologic assessments of a woman with granulomatous hypophysitis and interferon-induced thyroiditis are presented.ResultsA 42-year-old woman with hepatitis C was treated with interferon alfa-2b and ribavirin for 5 months. She was referred after symptoms of thyrotoxicosis developed, in conjunction with laboratory and radiographic evidence of thyroiditis. During the initial evaluation, she was weak and hypotensive; biochemical evaluation showed undetectable plasma cortisol and corticotropin concentrations. Magnetic resonance imaging revealed diffuse enlargement of the pituitary gland, which encroached on but did not compress the optic chiasm. Treatment with supraphysiologic doses of prednisone resulted in clinical and radiographic improvement. Once physiologic doses of glucocorticoids were instituted, however, follow-up magnetic resonance imaging showed substantial progression of the diffuse pituitary enlargement and mild compression of the optic chiasm. Surgical debulking of the mass and histologic evaluation showed chronic, noncaseating gran-ulomatous hypophysitis. An extensive evaluation for secondary causes of granulomatous inflammation of the pituitary revealed only an elevated angiotensin-converting enzyme level; no organisms were identified. After 2 courses of high-dose glucocorticoids, she had radiographic evidence of decreased size of the pituitary lesion but continued to have multiple anterior pituitary hormone deficiencies.ConclusionGranulomatous hypophysitis and sarcoidosis of the pituitary are rare disorders. Hypophysitis should be considered in patients receiving interferon and ribavirin therapy who have symptoms consistent with pituitary dysfunction. (Endocr Pract. 2007;13:169-175)