Recurrent pericardial effusion in a girl not responding to treatment

Author: Suwansh Meshram, Amit Nagpal, Tushar Jagzape, Bhavna Lakhkar

Question
A 13 years old girl resident of Yavatmal, Maharashtra born of non consanguineous marriage was admitted with chief complaints of decreased appetite and lethargy since one year and difficulty in breathing since 8 months. Patient had previous hospitalization one year back for persistent fever when she was diagnosed to have anemia with pericardial effusion and had received blood transfusion. Her previous report was also suggestive of TSH above the normal value for her age for which she was on thyroxine. Pericardial fluid report biochemistry and microbiological report was not available, but she was put on anti tubercular therapy.
On general examination, patient was afebrile. Her pulses were low volume with rate of 122 per minute. Blood pressure was 110, 70 mm Hg. Edema was present over feet. JVP was not raised. On auscultation, heart sounds were muffled. No murmur was noted. Respiratory system examination was normal. Per abdomen examination revealed hepatomegaly of 4-5 cm below costal margin. On further investigations, her complete blood count was within normal limit for her age. ESR was 4mm at end of one hour. Sickling was suggestive of ‘AA’ pattern. Her liver and kidney functions were normal for her age. Serum proteins were 7.4 gm percent. Echocardiography showed massive pericardial effusion with restricted ventricular function. Left ventricular ejection fraction was 54 percent and there were features of early cardiac temponade. Pericardial tap was done and pericardial fluid was suggestive of 2cells, cumm {most cells lymphocytes}, sugar was 84 mg percent, protein 0.86gm percent, LDH-1520 U, L. Microscopy did not reveal RBC or any pus cells` culture did not reveal any growth. Fluid was negative for AFB, Anti DS DNA and ANA. Pericardial fluid ADA was 10.3 u, l` Total cholesterol- 102 mg percent. We performed ultrasonography and CT abdomen to rule out any malignancy.
Patient was started on intravenous antibiotics-inj ampiclox as an empirical therapy, and then shifted on inj. Ceftazidime and vancomycin. 1000 ml of pericardial fluid was removed on first day. Echocardiography was performed after a day which was again suggestive of massive effusion, so pericardial pig tail catheter was placed to facilitate better drainage. Next day, 500 ml fluid was removed, then 250 ml. In seven days, daily approximately 250 ml fluid was drained through the catheter. Pericardial fluid microscopy repeated after a week showed 340 cells, cumm {neutrophils-40 percent, Lypmphocytes-60 percent}, serum proteins-5.1 gm percent. Despite antibiotic therapy for more than two weeks, patient was still getting pericardial fluid. So, as a last resort, empirical anti TB treatment was initiated along with Prednisolone therapy. Pericardial pig tail catheter was kept for three weeks, which drained around 200-300 ml of pericardial fluid daily.

$A 13 years old girl resident of Yavatmal, Maharashtra born of non consanguineous marriage was admitted with chief complaints of decreased appetite and lethargy since one year and difficulty in breathing since 8 months. Patient had previous hospitalization one year back for persistent fever when she was diagnosed to have anemia with pericardial effusion and had received blood transfusion. Her previous report was also suggestive of TSH above the normal value for her age for which she was on thyroxine. Pericardial fluid report biochemistry and microbiological report was not available, but she was put on anti tubercular therapy. <br>On general examination, patient was afebrile. Her pulses were low volume with rate of 122 per minute. Blood pressure was 110, 70 mm Hg. Edema was present over feet. JVP was not raised. On auscultation, heart sounds were muffled. No murmur was noted. Respiratory system examination was normal. Per abdomen examination revealed hepatomegaly of 4-5 cm below costal margin. On further investigations, her complete blood count was within normal limit for her age. ESR was 4mm at end of one hour. Sickling was suggestive of ‘AA’ pattern. Her liver and kidney functions were normal for her age. Serum proteins were 7.4 gm percent. Echocardiography showed massive pericardial effusion with restricted ventricular function. Left ventricular ejection fraction was 54 percent and there were features of early cardiac temponade. Pericardial tap was done and pericardial fluid was suggestive of 2cells, cumm {most cells lymphocytes}, sugar was 84 mg percent, protein 0.86gm percent, LDH-1520 U, L. Microscopy did not reveal RBC or any pus cells` culture did not reveal any growth. Fluid was negative for AFB, Anti DS DNA and ANA. Pericardial fluid ADA was 10.3 u, l` Total cholesterol- 102 mg percent. We performed ultrasonography and CT abdomen to rule out any malignancy. <br>Patient was started on intravenous antibiotics-inj ampiclox as an empirical therapy, and then shifted on inj. <a class='interlink' href='/drugs/antimicrobial-cephalosporins/ceftazidime/23/386'>Ceftazidime</a> and vancomycin. 1000 ml of pericardial fluid was removed on first day. Echocardiography was performed after a day which was again suggestive of massive effusion, so pericardial pig tail catheter was placed to facilitate better drainage. Next day, 500 ml fluid was removed, then 250 ml. In seven days, daily approximately 250 ml fluid was drained through the catheter. Pericardial fluid microscopy repeated after a week showed 340 cells, cumm {neutrophils-40 percent, Lypmphocytes-60 percent}, serum proteins-5.1 gm percent. Despite antibiotic therapy for more than two weeks, patient was still getting pericardial fluid. So, as a last resort, empirical anti TB treatment was initiated along with <a class='interlink' href='/drugs/corticosteroids/prednisolone/38/891'>Prednisolone</a> therapy. Pericardial pig tail catheter was kept for three weeks, which drained around 200-300 ml of pericardial fluid daily. <br><br></table>$