Un-Break My Heart: A Case Report on the Importance of Monitoring Malignant Pericardial Effusions in Cancer Rehabilitation

Case Diagnosis: Malignant Pericardial Effusion

Case Description or Program Description: The patient is a 37-year-old woman with a history of metastatic breast cancer, complicated by malignant pleural and pericardial effusions. She was admitted to rehab for debility in the setting of cancer progression. Before admission, her effusions were stabilized following talc pleurodesis, PleurX catheter placement, and a pericardial window. During her rehab admission, she commenced chemotherapy. A transthoracic echocardiogram (TTE) performed the day before her first chemotherapy session demonstrated a stable pericardial effusion. A day after chemotherapy initiation, she reported new onset dysphagia, odynophagia, and globus sensation, which was unresponsive to acid reflux management.

Setting: Acute inpatient rehabilitation.

Assessment/Results: The patient experienced a progressive decline, evidenced by decreased participation in therapy and regression in bedside swallow evaluations. Despite this decline, she did not endorse new pulmonary or cardiac symptoms. Gastroenterology was consulted for an endoscopy, but the patient deferred due to odynophagia, opting instead for computed tomography (CT) of the abdomen. The CT scan revealed distal esophageal collapse secondary to mass effect from her adjacent pericardial effusion, which had significantly worsened over 5 days. Shortly thereafter, the patient began tripoding and developed cardiogenic shock, necessitating transfer to the intensive care unit for emergent pericardiocentesis.

Discussion (relevance): Worsening pericardial effusion was initially considered unlikely, as she presented with dysphagia rather than cardiac symptoms. Additionally, she had previously undergone a pericardial window, had a stable effusion on TTE a few days prior, and oncology did not anticipate this as a side effect of her chemotherapy. This case illustrates the rapid evolution of a medical condition, underscoring the importance of considering worsening pericardial effusions in the differential diagnosis, even when improbable.

Conclusions: Malignant pericardial effusions from metastatic cancer can progress rapidly and may present differently than the expected manifestations of cardiac tamponade or pericarditis. Therefore, close monitoring is essential for these patients in cancer rehabilitation.