Uncovering the diagnosis

JBS (Medicine Resident): A 63-year-old African-American woman presented to the emergency department with progressive dyspnoea of 2-weeks’ duration. She denied chest pain, palpitations or syncope. Her medical history was significant for hypertension and diabetes mellitus. She never smoked and denied occupational exposures. She was born and raised in New York State, taking annual trips to North Carolina. On examination, she was obese and appeared dyspnoeic. She was afebrile with a blood pressure of 152/74 mm Hg, a heart rate of 98 bpm, a respiratory rate of 20/min and an oxygen saturation of 97% while breathing ambient air. The jugular venous pulse was elevated. Heart sounds were normal, and there was no murmur, gallop, rub or click. Lungs were clear to auscultation and percussion. There was trace pedal oedema. The remainder of the examination was unremarkable. Initial laboratory evaluation was notable for a serum glucose level of 260 mg/dL (normal range 74–126 mg/dL). Complete blood count and serial troponin measurements were normal. The ECG revealed sinus tachycardia at 100 bpm with borderline low QRS voltage and rare ectopy (figure 1A). The chest radiograph showed an increase in the cardiac silhouette compared with a film obtained 10 months earlier (figure 1B–D). There was no pulmonary vascular congestion, but tiny pleural effusions were seen on the lateral projection. Echocardiography demonstrated a large pericardial effusion (figure 1E) with diastolic inversion of the right atrial and right ventricular free walls consistent with tamponade physiology. Left ventricular size and function were normal. The patient underwent pericardiocentesis, which yielded 860 mL of clear yellow, lymphocyte-predominant fluid. Biochemical analysis revealed lactate dehydrogenase—130 U/L (serum 276 U/L), total protein—5.8 g/dL (serum 7.9 g/dL) and glucose—162 mg/dL. Figure 1 (A) ECG showing sinus tachycardia at 100 bpm with atrial premature complexes and borderline low QRS voltage. (B) Posteroanterior chest radiograph with an enlarged cardiac silhouette and clear lung fields. (C) Lateral …