Cardiac tamponade as the initial presentation of Hodgkin’s lymphoma in a young female

Introduction: Hodgkin’s lymphoma can affect the heart both as primary and as a metastatic condition. Pericardial compromise is a common finding over the course of the disease, and the manifestations can range from pericarditis to pericardial tamponade. Pericardial tamponade is a life-threatening condition that requires immediate treatment, and is rarely the initial presentation of Hodgkin’s lymphoma. We present a case of a young female with Hodgkin’s lymphoma initially presenting as acute pericardial tamponade. Case Report: A 20-year-old female presented with acute shortness of breath. At presentation she was hypotensive, tachycardic, and tachypneic. Chest X-ray showed an enlarged mediastinum, without enlarged cardiac silhouette. Bedside transthoracic echocardiography demonstrated massive pericardial effusion with cardiac tamponade. The patient was in critical condition, and a pericardial window was performed. After the procedure she was hemodynamically stable. Positron emission tomography scan and computed tomography evidenced a ganglionar conglomerate in the mediastinum and supraclavicular area. An excisional biopsy of a neck lymph node confirmed classical Hodgkin’s lymphoma. She was started with standard chemotherapy induction. At the time of the report the patient is doing well with favorable response to the treatment, and without any clinical evidence of systemic or cardiac recurrence. Conclusion: Pericardial involvement is frequent over the course of Hodgkin lymphoma. Pericardial tamponade is rarely the initial presentation of Hodgkin’s lymphoma. A team approach is necessary for favorable outcome. Treatment consists of stabilizing the patient by relieving the tamponade, followed by systemic chemotherapy treatment for the underlying malignancy and to prevent recurrence. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 6 No. 11, November 2015. ISSN – [0976-3198] Int J Case Rep Images 2015;6(11):686–689. www.ijcasereportsandimages.com Gonzalez et al. 686 CASE REPORT OPEN ACCESS Cardiac tamponade as the initial presentation of Hodgkin’s lymphoma in a young female Miguel Gonzalez, Amado Karduss-Urueta, Laura Gutiérrez, Juan Alejo Jimenez, Rosendo Perez


AbstrAct
Introduction: Hodgkin's lymphoma can affect the heart both as primary and as a metastatic condition. Pericardial compromise is a common finding over the course of the disease, and the manifestations can range from pericarditis to pericardial tamponade. Pericardial tamponade is a life-threatening condition that requires immediate treatment, and is rarely the initial presentation of Hodgkin's lymphoma. We present a case of a young female with Hodgkin's lymphoma initially presenting as acute pericardial tamponade. case report: A 20-yearold female presented with acute shortness of breath. At presentation she was hypotensive, tachycardic, and tachypneic. chest X-ray showed an enlarged mediastinum, without enlarged cardiac silhouette. bedside transthoracic echocardiography demonstrated massive pericardial effusion with cardiac tamponade. the patient was in critical condition, and a pericardial window was performed. After the procedure she was hemodynamically stable. Positron emission tomography scan and computed tomography evidenced a ganglionar conglomerate in Miguel González 1 , Amado Karduss-Urueta 2 , Laura Gutiérrez 3 , Juan Alejo Jiménez 3 [1]. Commonly, the initial clinical presentation is with painless localized peripheral lymphadenopathy, typically involving the cervical region. Over the course of disease Hodgkin's lymphoma can have different types of pericardial involvement. Manifestations can range from an asymptomatic mild effusion to acute pericardial tamponade [2,3]. Pericardial tamponade is an acute condition that requires immediate treatment; and is rarely the initial presentation of Hodgkin's lymphoma [4][5][6][7]. Herein, we present a case of a young female with Hodgkin's lymphoma initially presenting as acute pericardial tamponade.

cAsE rEPOrt
A previously healthy 20-year-old female presented to the emergency department with progressive shortness of breath. On clinical examination she was conscious, had fatigue, cough, swelling of the neck and evident respiratory distress. At presentation she was hypotensive (blood pressure 90/60 mmHg), tachycardic (pulse 125 beats/ minute), and tachypneic (respiratory rate 27 respirations/ minute), and temperature was 37°C. Electrocardiogram showed normal sinus rhythm with sinus tachycardia. Chest X-ray ( Figure 1) showed an enlarged mediastinum, encompassing 60% of the internal transverse diameter of the thorax, without enlarged cardiac silhouette. Bedside transthoracic echocardiography demonstrated massive pericardial effusion with cardiac tamponade. The patient was in critical condition and was shifted emergently to the operating room where she was evaluated by cardiovascular surgery. A pericardial window was performed via subxiphoid incision. The pericardial sac was tense and the pericardium was opened anterior to the phrenic nerve. About 400 mL of bloody fluid was gradually suctioned from the pericardial cavity, and 300 mL from the right pleural space. The pericardium had normal appearance and no cardiac injuries could be identified. The pericardium was inspected and a large swelling was found in the middle mediastinum compressing the heart, the fluid was drained, fluid studies and a biopsy were performed and the bleeding was controlled by applying an absorbable hemostat. Pericardiopleural window was created posterior to the phrenic nerve and the chest was closed after inserting a thoracic drain. After the procedure she was hemodynamically stable. Chest computed-tomography scan evidenced a great ganglionar conglomerate in the anterior and medium mediastinum with a mediastinal mass of 150x100x130 mm with secondary stenosis of the superior vena cava. The cardiac biopsy and the fluid studies were negative for malignancy.
An excisional biopsy of an easily accessible neck lymph node was taken and sent for pathology and immunologic studies. The biopsy confirmed a lymphoproliferative disease consistent with classical Hodgkin's lymphoma of the nodular sclerosing subtype. Cytology evidenced the presence of large mononuclear cells and the classical Reed-Sternberg cells which were CD 30+. A staging positron emission tomography/computer tomography (PET/CT) scan (Figure 2) was performed and the patient was staged as a Hodgkin's lymphoma, stage III-2 (Both sides of diaphragm), A (No B symptoms), X (presence of bulky disease larger than 10 cm) according to Ann Arbor classification. She had compromise of retroperitoneal lymph nodes but without hepatic, splenic, or bone marrow compromise. The patient had three negative prognostic factors based on the International Prognostic Score (IPS); with a calculated 60% freedom from progression and 78% overall survival at five years. She was started with standard induction chemotherapy with adryamicin, bleomycin, vinblastine, and dacarbazine (ABVD). At the time of the report the patient has received the six cycles of chemotherapy and is doing well with favorable response Figure 1: Chest X-ray with widened mediastinum at the initial presentation. to the treatment (Figures 2 and 3), and without any clinical or imagenological evidence of systemic or cardiac recurrence.

DIscUssION
Hodgkin's lymphoma is a hematological malignancy with an incidence of 2-4 per 100,000 per year [1]. The most common presentation consists of a painless mass in >70% of the cases. Pericardial involvement is a common finding over the course of the disease, and it can present either as a primary or as a metastatic condition. Pericardial compromise can be asymptomatic or present with manifestations that range from pericarditis to pericardial tamponade [5,7]. The clinical presentation of pericardial effusions depends upon whether the accumulation is acute or subacute.
Acute pericardial tamponade is a life-threatening condition that requires immediate diagnosis and treatment and is rarely the first presenting sign of Hodgkin's lymphoma [6,8,9]. The clinical presentation of acute pericardial tamponade includes: sudden dyspnea, chest pain, tachycardia, softening of heart sounds and echocardiographic signs of right heart compromise secondary to the acute rise in the pericardial pressure limiting the diastolic filling and leading to hemodynamic instability.
The diagnostic approach of pericardial tamponade includes a combination of electrocardiography, radiologic studies, and diagnostic/therapeutic pericardiocentesis.
Chest X-ray can show an enlarged cardiac silhouette with clear lung fields. Echocardiography is the primary imaging tool to establish the diagnosis and quantify the amount of pericardial effusion and the hemodynamic impact on the patient. Imaging with computed tomography scan and positron emission tomography scan can provide additional information and can be useful in the evaluation of patients. Pericardial biopsy and examination of the pericardial fluid should be done to perform cytology studies and biomarkers and to rule out other diagnosis [2,10].
Hodgkin's lymphoma has a good prognosis when treated promptly with chemotherapy. In patients presenting with acute symptoms of pericardial tamponade the mainstay of treatment is the removal of the fluid to obtain normal hemodynamic status and stabilize the patient by relieving the tamponade. A team approach including cardiologist, surgeon, anesthetist, radiologist and oncologist is necessary for favorable outcome. Following the stabilization of the hemodynamic parameters, staging should be completed and induction chemotherapy treatment initiated as soon as possible to treat the underlying disease and prevent reaccumulation of pericardial fluid. Our patient received appropriate acute management of the tamponade and received induction chemotherapy without recurrence of the pericardial fluid.

cONcLUsION
Pericardial involvement is a frequent finding in Hodgkin's lymphoma but is rarely the initial presentation. Given its rarity it is hard to give a specific recommendations regarding diagnosis, but clinical suspicion should remain high in an appropriate clinical context. Diagnosis and treatment should be directed depending on the presentation; with a team approach necessary for favorable outcomes. This atypical presentation should be suspected and promptly confirmed with imaging. Initial treatment consists of stabilizing the patient by relieving the tamponade, followed by systemic induction chemotherapy treatment for the underlying malignancy and to prevent fluid reaccumulation. *********

AN INTRODUCTION
Edorium Journals: On Web

About Edorium Journals
Edorium Journals is a publisher of high-quality, open access, international scholarly journals covering subjects in basic sciences and clinical specialties and subspecialties.

Edorium Journals: An introduction
Edorium Journals Team

But why should you publish with Edorium Journals?
In less than 10 words -we give you what no one does.

Vision of being the best
We have the vision of making our journals the best and the most authoritative journals in their respective specialties. We are working towards this goal every day of every week of every month of every year.

Exceptional services
We care for you, your work and your time. Our efficient, personalized and courteous services are a testimony to this.

Editorial Review
All manuscripts submitted to Edorium Journals undergo pre-processing review, first editorial review, peer review, second editorial review and finally third editorial review.

Peer Review
All manuscripts submitted to Edorium Journals undergo anonymous, double-blind, external peer review.

Early View version
Early View version of your manuscript will be published in the journal within 72 hours of final acceptance.

Manuscript status
From submission to publication of your article you will get regular updates (minimum six times) about status of your manuscripts directly in your email.

Most Favored Author program
Join this program and publish any number of articles free of charge for one to five years.

Favored Author program
One email is all it takes to become our favored author. You will not only get fee waivers but also get information and insights about scholarly publishing.

Institutional Membership program
Join our Institutional Memberships program and help scholars from your institute make their research accessible to all and save thousands of dollars in fees make their research accessible to all.

Our presence
We have some of the best designed publication formats. Our websites are very user friendly and enable you to do your work very easily with no hassle.

Something more...
We request you to have a look at our website to know more about us and our services.
We welcome you to interact with us, share with us, join us and of course publish with us.

Invitation for article submission
We sincerely invite you to submit your valuable research for publication to Edorium Journals.

Six weeks
You will get first decision on your manuscript within six weeks (42 days) of submission. If we fail to honor this by even one day, we will publish your manuscript free of charge.

Four weeks
After we receive page proofs, your manuscript will be published in the journal within four weeks (31 days). If we fail to honor this by even one day, we will publish your manuscript free of charge and refund you the full article publication charges you paid for your manuscript.