Pericardial effusion – forgotten differential diagnosis of shortness of breath

Editor – I read with great interest Nijjer et al's excellent paper (Clin Med February 2010 pp 88–90). Delayed pericardial effusion can also be related to primary lung tumours or haematological tumours.¹ In acute medicine, when a patient with known left ventricular dysfunction presents with shortness of breath, the most obvious diagnosis is heart failure. However, I have recently seen a case of a 70-year-old gentleman who was known to have moderate left ventricular systolic dysfunction and atrial fibrillation. He was admitted acutely with symptoms and signs suggestive of decompensated heart failure. His presenting electrocardiogram (ECG) confirmed atrial fibrillation and had poor R-wave progression. He was started on intravenous diuretics and also rate control antiarrhythmic drugs. He responded slightly to treatment and was also noted to be hypoxic on air. His chest X-ray revealed pulmonary congestion with some right upper lobe consolidation and cardiomegaly. A computed tomography pulmonary angiogram was organised which showed gross pericardial effusion and also a primary lung tumour in the right upper lobe. Retrospective analysis of his serial chest X-ray revealed that his cardiomegaly had worsened markedly in two months.

If this gentleman had a bedside echocardiogram done on his presentation, his diagnosis would have been made immediately and a prompt treatment strategy could have been started. Therefore, it is prudent to consider pericardial effusion in a patient presenting with shortness of breath, globular heart on chest X-ray and poor R-wave progression on ECG, irrespective of past medical history. A suspicion of pericardial effusion should lead to prompt bedside echocardiogram by an echocardiographer or acute physician trained in basic skills of echocardiography.²

• © 2010 Royal College of Physicians