Case Author(s): Dennis Hsueh, M.D. and Tom R. Miller, M.D., Ph.D. , 11/29/03 . Rating: #D2, #Q3

Diagnosis: Pericardial effusion

Brief history:

Patient with Hodgkin’s lymphoma treated with chemotherapy.

Images:

Anterior, Best septal, and Lateral images from a cardiac blood pool study.

View cine in AVI format.

View main image(ca) in a separate image viewer

View second image(xr). Top images: Frontal and lateral views from a chest radiograph. Obtained on the same day as the Tc-99m-RBC cardiac blood pool examination. Bottom Image: Static end-diastolic (ED) and end-systolic (ES) images from the Tc-99m-RBC cardiac blood pool examination.

Full history/Diagnosis is available below

Diagnosis: Pericardial effusion

Full history:

Thirty two year-old man with history of Hodgkin’s lymphoma treated with chemotherapy. Cardiac blood pool imaging examination has been requested to evaluate post chemotherapy cardiac function. EKG (not shown) demonstrates low-voltage QRS complex.

Radiopharmaceutical:

Tc-99m in vivo labeled red blood cells

Findings:

Cardiac Blood Pool Imaging: Anterior, best septal (left anterior oblique), and lateral gated images of the heart demonstrate marked separation of the cardiac chambers from the liver with a large halo of absent tracer activity surrounding the cardiac chambers consistent with a pericardial effusion. The cardiac chambers and great vessels are of normal size and configuration. Cine images demonstrate normal left and right ventricular contractility. The calculated left ventricular ejection fraction is 50%, within the normal range.

Chest radiograph: There is thickening of the right paratracheal stripe and tracheal deviation consistent with lymphadenoapathy. Cardiac silhouette enlargement (water bottle configuration) is compatible with the large pericardial effusion.

Discussion:

Inflammation of the pericardium or obstruction of lymphatic drainage from the pericardium leads to a pericardial effusion. Malignant pericardial effusions may result from seeding from a remote or nearby focus of malignancy or by direct extension.

When pericardial effusions develop, cardiac chamber capacity may be reduced. Because venous return may be impaired, cardiac output would be limited. Slow accumulation of large amounts of fluid may collect without producing clinical symptoms. On the other hand, rapid accumulation of fluid is tolerated poorly with nonspecific symptoms of dyspnea, chest or shoulder pain, or orthopnea. Physical examination demonstrates a paradoxical pulse, jugular venous distension, faint heart sounds, and a friction rub. EKG changes are nonspecific but include low voltage QRS complexes, ST segment elevation, T wave inversion and development of arrhythmias. Electrical alternans, (beat-to-beat) variation in QRS amplitude, occurs with excessive motion of the heart within the fluid-filled pericardial space.

In cardiac blood pool or cardiac perfusion imaging examinations, absence of tracer activity around the cardiac chambers or myocardium, respectively, is due to a pericardial effusion that may be comprised of serous fluid, hemorrhagic fluid, purulent debris, or chylous fluid (or a combination).

On echocardiography, pericardial effusions are characterized by sonolucency between the visceral and parietal pericardium.

Treatment of a pericardial effusion involves correcting the underlying cause. Pericardiocentesis may be performed in patients with impending tamponade. Pericardiotomy may be performed if effusions recur. Rarely pericardial sclerosis may be performed on recurrent effusions using sclerosing agents such as tetracycline or doxycycline.

Followup:

This patient had a history of a large pericardial effusion caused by lymphatic obstruction from lymphadenopathy. The patient had been treated with a pericardiotomy in the past. Although the effusion persists, cardiac output is not impaired.

REFERENCES:

Strimel WJ and Noe S. (2002, October 9). Pericardial Effusion. eMedicine. Retrieved November 29, 2003, from http://www.emedicine.com/med/topic1786.htm.

Venugopalan, P. (2003, July 1). Pericardial Effusion, Malignant. eMedicine. Retrieved November 29, 2003, from http://www.emedicine.com/ped/topic1764.htm.

Sprengelmeyer JT et al. (1990), Journal of Nuclear Medicine. “Phosphorous 32 colloidal chromic phosphate: treatment of choice for malignant pericardial effusion.” 31:2034-6.

View followup image(ct). Images from CT chest examination (obtained 6 weeks prior to the cardiac blood pool examination) demonstrate a large infiltrative mass with central necrosis in the anterior mediastinum. Mediastinal lymphadenopathy extends to the right hilum. Right axillary, paratracheal, bilateral supraclavicular and hilar lymphadenopathy are also demonstrated. CT of the neck, abdomen and pelvis (images not shown) revealed extensive cervical lymphadenopathy. No abdominal lymphadenopathy or splenomegaly is appreciated.

Major teaching point(s):

Please see above discussion.

Differential Diagnosis List

Absence of tracer activity around the cardiac chambers is most likely due to a pericardial effusion. Decreased tracer activity around the cardiac chambers can also result from attenuation by a large pericardial fat pad or from a large breast. Patients with emphysema can also demonstrate decreased activity around the cardiac chambers due to a larger volume of absent activity in air containing alveoli or bullae relative to the activity present from blood in lung parenchyma. The halo of absent activity in these latter examples (fat pad or breast attenuation or emphysema) does not extend uniformly under and around the heart.

ACR Codes and Keywords:

References and General Discussion of Cardiac Blood Pool Scintigraphy (Anatomic field:Heart and Great Vessels, Category:Organ specific)

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Case number: ca008

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