5904An unusual case of recurrent large pericardial effusion with pre-tamponade

Case presentation: A 59-years-old man with no previous cardiological history and no CV risk factors was admitted to the Emergency Department with progressive and worsening dyspnoea in January 2017. Previous history. He complained previous chest discomfort and dyspnoea on exertion in May 2016 with negative diagnostic tests. In October 2016 he performed an ambulatory abdominal US showing a large pericardial effusion, then he was admitted to the CCU and pericardiocentesis was performed with drainage of 2800 mL of serum-haemorrhagic fluid. Lab tests did not show increased markers of inflammation. Then a complete aetiological screening was performed: RF, ANA, ENA, LAC, TSH, ACE, Wright and Weil Felix test, CMV IgM, HSV1/2 IgM, EBV IgM, Borrelia Burgdorferi IgM, urinary Legionella Ag, search for BK in the fluid, Tine Test. All tests were negative. Also cytological examination of the fluid was negative for malignancy. Chest/Abdomen CT scan and PET were both normal. During hospital stay many echocardiograms showed a circumferential severe cardiac pericardial effusion (>20 mm) with right atrial collapse, without signs of cardiac tamponade. One additional pericardiocentesis of 1600 mL serous fluid was performed. He started corticosteroids (Prednisone 50 mg x 2 and then 25 mg x 2), but the large effusion recurred again. He finally started the complete treatment with Ibuprofen 600 mg x 3/day, prednisone 50 mg/day, and Colchicine 0,5 mg x2/day. No improvement in symptoms was seen. Current admission. Since a large pericardial fluid with pre-tamponade was detected on TTE, pericardiocentesis was performed with pericardial drainage left after the procedure. Daily pericardial drainage was respectively: 500–250–400–200–100–120 ml. The pericardial fluid was analysed once more: general chemistry suggested an inflammatory fluid (exudate); cytology and microbiology were negative as well. After pericardial drainage removal, a new TTE showed recurrence of a large pericardial effusion (maximum 34 mm) after 2 days. After cardiac surgeon consultation a total pericardiectomy was planned. During the surgical operation TOE monitoring revealed an abnormal morphology of the left atrium appendage (LAA). On surgical exploration a pericardial mass close to the LAA was observed (figure). The surgical operation was changed as LAA and mass complete resection, anterior pericardiectomy, and pericardial window. On histology the mass was diagnosed as a benign haemangioma.