Cardiac Tamponade as First Indicator of Metastatic Gastric Adenocarcinoma
Ashley Russell, MD; Tulane University Internal Medicine Residency
Introduction : Learning Objectives - Recognize that a patient’s first episode of tamponade can signal recurrent gastric adenocarcinoma. - Increase awareness of adenocarcinoma ’s aggressive nature in malignant pericardial effusion leading to tamponade. Case Presentation: A 74-year-old veteran with CAD s/p PCI, HIV with undetectable viral load, and primary gastric cancer treated with radiation and partial gastrectomy in 2017 presented with three days of nausea and vomiting was admitted for an AKI. Three months prior he was seen by his oncologist and informed still in remission. He denied any history of chemotherapy, HIV complications, or history of pericardial effusion. One day into admission he became short of breath, hypotensive, and tachycardic. Exam was pertinent for JVD and distant heart sounds. He was transferred to the CCU and underwent an emergent bedside pericardiocentesis with drainage of approximately 900 cc of bloody fluid. Cardiogenic shock and hypoxic respiratory failure resolved after pericardiocentesis. CT spine and MRI showed lytic lesions throughout the spine, consistent with metastatic disease. Cytology of the pericardial fluid revealed adenocarcinoma with immunehistochemical findings supportive of metastatic gastric cancer. Discussion: Malignancy is a well established etiology of pericardial effusions. The frequency of hemorrhagic and symptomatic pericardial effusions from malignancy is reported to be 26% 1 and 33%, 2 respectively. This case illustrates that tamponade in a previously asymptomatic patient can be the first sign of gastric adenocarcinoma recurrence. There is a small number of case reports 3-9 that demonstrate recurrent and primary gastric adenocarcinoma can manifest alone with tamponade. Literature review shows patients with other forms of adenocarcinoma such as lung, ovarian and colon 10-12 can present in tamponade. The frequency of pericardial effusions from gastric cancer is low at 5.3%. 13 However, the startling fact about gastric and other forms of adenocarcinoma is they involve the pericardium at more aggressive rates 14 than other cancers.
Conclusion: It is important to consider adenocarcinoma in the case of pericardial effusion/tamponade and recognize that tamponade can signal recurrence of malignancy in a patient who has never had a pericardial effusion.
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