Pericardial effusion in children: Experience from tertiary care center in Northern India

Aetiological distribution and clinical features in children with large pericardial effusion who underwent pericardiocentesis

BACKGROUND

We aimed to evaluate the clinical and laboratory characteristics and aetiological factors of patients who underwent pericardiocentesis for moderate to large pericardial effusion.

METHOD

A total of 38 patients who underwent pericardiocentesis due to moderate-severe pericardial effusion and not related to cardiac surgery were included in the study.

RESULTS

The male-to-female ratio was 2.16, and found to be 7.5 in patients over 3 years of age. Mean age and body weight of the patients were 69.4 ± 74.9 months and 22.5 ± 22.4 kg. Dyspnoea (51.7%) was the most common complaint, followed by chest pain (37.9%). Tamponade was present in 23.7% of the patients. The largest diameter of effusion was 24.4 ± 10.4 mm. The amount of fluid drained was 279.24 ± 279 ml. Macroscopic appearance was serous in 12 (34.3%), and haemorrhagic in 18 (51.4%). No complication related to procedure was seen. Aetiology for efusion was infectious in 26%, idiopathic in 18%, iatrogenic in 11%, rheumatological in 11%, malignancy in 8%, cardiomyopathy in 8%, and other factors related in 18%. Of the 38 patients, 16 received nonsteroidal anti-inflammatory drugs (NSAID), and colchicine and corticostreoid were added in nine and two patients, respectively. A total of eight (21%) patients died during follow-up.

CONCLUSION

In conclusion, percutaneous pericardiocentesis can be applied safely and the underlying aetiology is decisive in the prognosis of the patient. Although pericardial effusion in children is often due to inflammation of the pericardium, it can develop as a finding of many local or systemic diseases that should be kept in mind.

Incidence of secondary pericardial effusions associated with different etiologies: a comprehensive review of literature

Pericardial effusion is a relatively common complication associated with inflammatory and non-inflammatory diseases. The primary etiology of this condition could be considered when choosing therapeutic options and factors such as effusion size and its hemodynamic consequence. In most cases, small to moderate pericardial effusions can be managed with observation and anti-inflammatory medications unless the effusion develops rapidly. However, in a small proportion of patients, large effusions lead to impaired cardiac filling with hemodynamic compromise and cardiovascular collapse due to cardiac tamponade. The rate at which fluid accumulates is the primary determinant of hemodynamic impact and thus guides the choice of treatment, irrespective of the effusion's size. Severe cases are typically treated with pericardiocentesis with echocardiographic guidance. More aggressive treatments may be necessary for cases due to purulent or malignant etiologies. These cases may require a pericardial window to allow for long-term drainage of the pericardial fluid. This comprehensive review focuses on the epidemiology of pericardial effusion and discusses pathophysiology, diagnostic approaches, and therapeutic options for different causes of secondary pericardial effusions.

Pericardial effusion in an Indian context: clinical insights and dynamics from a tertiary care centre

BACKGROUND

Pericardial effusion (PE) indicates the build-up of fluid within the pericardial sac, which encases the heart. The present study was undertaken to assess the clinical profile, etiology of pericardial effusion and to determine the correlation of cardiac tamponade and constrictive pericarditis with etiology.

METHODS

A prospective observational hospital based longitudinal study was undertaken among the 88 newly diagnosed and known patients of pericardial effusion who are above 18 years. The clinical profile of pericardial effusion including history, examination, standard lab parameters routinely done including thyroid function tests, HIV Serology, ECG, Echocardiography and imaging if done (HRCT thorax), pericardial fluid analysis (if performed) were elicited.

RESULTS

Majority of the patients were males (55.7%), with a mean age of 51.3 years. Among the 88 patients of pericardial effusion, 20 had cardiac tamponade, 13 individuals were diagnosed with constrictive pericarditis. Dyspnea was the most common presenting complaint (65.9%). Chronic kidney disease / uremia is the most common cause of pericardial effusion accounting for 25%, followed by neoplastic (20.5%) and tuberculosis (17%). While in cardiac tamponade patients neoplasm followed by tuberculosis were the most common etiology, patients with constrictive pericarditis had tuberculosis followed by chronic kidney disease as the most common etiology. Echocardiography features were not significantly different according to the etiology of the pericardial effusion (p > 0.05). Thickened pericardium found in the echocardiography showed maximum specificity (76.9%), while thickened fluid/exudates showed maximum sensitivity (65.2%) and negative predictive value (77.1%) for tuberculous pericardial effusion.

CONCLUSION

Chronic kidney disease, closely followed by infections (mostly tuberculosis), are the frequent causes of PE in the present settings. Breathlessness is the most frequent clinical feature in the patients of PE. Fibrin strands, thickened pericardium, thickened fluid in Echocardiography assists in diagnosing tubercular pericardial effusion. Cardiomegaly in chest X-ray or CT scans should further prompt towards diagnosing pericardial effusion. It is essential to incorporate these findings into the clinical practice, by evaluating the patients presenting with breathlessness for PE. CKD needs to be placed on par with tuberculosis while suspecting the etiology of the PE in the present settings. ADA levels in pericardial fluid (> 40) can be considered as a specific marker for tubercular PE.

Tuberculous Pericarditis in Childhood: A Case Report and a Systematic Literature Review

Tuberculous pericarditis (TBP) is an important cause of pericarditis worldwide while being infrequent in childhood, especially in low-TB-incidence countries. We report a case of TBP and provide a systematic review of the literature, conducted by searching PubMed, Scopus, and Cochrane to find cases of TBP in pediatric age published in the English language between the year 1990 and the time of the search. Of the 587 search results obtained, after screening and a backward citation search, 45 studies were selected to be included in this review, accounting for a total of 125 patients. The main signs and symptoms were fever, cough, weight loss, hepatomegaly, dyspnea, and increased jugular venous pressure or jugular vein turgor. A definitive diagnosis of TBP was made in 36 patients, either thanks to microbiological investigations, histological analysis, or both. First-line antitubercular treatment (ATT) was administered in nearly all cases, and 69 children underwent surgical procedures. Only six patients died, and only two died of TBP. TBP in childhood is relatively uncommon, even in high-TB-prevalence countries. Clinical manifestations, often suggestive of right-sided cardiac failure, are subtle, and diagnosis is challenging. TBP has an excellent prognosis in childhood; however, in a significant proportion of cases, invasive surgical procedures are necessary.

Pericardial effusion in children at tertiary national referral hospital, Addis Ababa, Ethiopia: a 7-year institution based review

BACKGROUND

Pericardial effusion (PE) is a rare yet an important cause of child mortality due to collection of excess fluid in pericardial space. The study aimed to describe the PE profile in the national cardiac referral hospital, Addis Ababa, Ethiopia.

METHODS

The study employed cross-sectional study design for a 7-year review of childhood PE in Tikur Anbessa Specialized Hospital. Descriptive and analytic statistics were applied.

RESULTS

There were 17,386 pediatric emergency/ER admissions during the study period, and PE contributed to 0.47% of ER admissions. From 71 included subjects, 59% (42) were males with mean age of 7.8 ± 3.3 years. Cough or shortness of breath,73.2% (52) and fever or fast breathing, 26.7% (19), were the common presenting symptoms. The median duration of an illness before presentation was 14days (IQR: 8-20). The etiologies for pericardial effusion were infective (culture positive-23.9%, culture negative-43.6%, tuberculous-4.2%), hypothyroidism (4.2%), inflammatory (12.7%), malignancy (7%) or secondary to chronic kidney disease (1. 4%). Staphylococcus aureus was the most common isolated bacteria on blood culture, 12.7% (9) while the rest were pseudomonas, 7% (5) and klebsiella, 4.2% (3). Mild, moderate and severe pericardial effusion was documented in 22.5% (16), 46.5% (33), and 31% (22) of study subjects, respectively. Pericardial tamponade was reported in 50.7% (36) of subjects. Pericardial drainage procedure (pericardiocentesis, window or pericardiotomy) was performed for 52.1% (37) PE cases. The case fatality of PE was 12.7% (9). Pericardial drainage procedure was inversely related to mortality, adjusted odds ratio 0.11(0.01-0.99), p 0.049).

CONCLUSION

PE contributed to 0.47% of ER admissions. The commonest PE presentation was respiratory symptoms of around two weeks duration. Purulent pericarditis of staphylococcal etiology was the commonest cause of PE and the case fatality rate was 12.7%. Pericardial drainage procedures contributed to reduction in mortality. All PE cases should be assessed for pericardial drainage procedure to avoid mortality.

The Epidemiology and Outcome of Pericardial Effusion in Hospitalized Children: A National Database Analysis

OBJECTIVES

To describe the epidemiology of pericardial effusion in hospitalized children and evaluate risk factors associated with the drainage of pericardial effusion and hospital mortality.

STUDY DESIGN

A retrospective study of a national pediatric discharge database.

RESULTS

We analyzed hospitalized pediatric patients from the neonatal age through 20 years in the Kids' Inpatient Database 2016, extracting the cases of pericardial effusion. Of the 6 266 285 discharged patients recorded, 6417 (0.1%) were diagnosed with pericardial effusion, with the highest prevalence of 2153 patients in teens (13-20 years of age). Pericardial effusion was drained in 792 (12.3%), and the adjusted risk of pericardial drainage was statistically low with rheumatologic diagnosis (OR, 0.485; 95% CI, 0.358-0.657, P < .001). The overall mortality in children with pericardial effusion was 6.8% and 10.9% of those who required pericardial effusion drainage (P < .001). The adjusted risk of mortality was statistically high with solid organ tumor (OR, 1.538; 95% CI, 1.056-2.239, P = .025) and pericardial drainage (OR, 1.430; 95% CI, 1.067-1.915, P = .017) and low in all other age groups compared with neonates, those with cardiac structural diagnosis (OR, 0.322; 95% CI, 0.212-0.489, P < .001), and those with rheumatologic diagnosis (OR, 0.531; 95% CI, 0.334-0.846, P = .008).

CONCLUSION

The risk of mortality in hospitalized children with pericardial effusion was higher in younger children with solid organ tumors and those who required pericardial effusion drainage. In contrast, it was lower in older children with cardiac or rheumatologic diagnoses.

A Child with Massive Pericardial and Pleural Effusion and Chronic Granulomatous Disease

Introduction: chronic granulomatous disease (CGD) is a genetic disease characterized by recurrent life-threatening fungal and bacterial infections and granuloma formation. Pericardial effusion is rare in this disease. Case Presentation: The study reports a 13-year-old boy with CGD and a history of recurrent infections such as pneumonia and abscesses. The patient presented with shortness of breath, cough, abdominal pain, and chest pain and was diagnosed with severe pericardial and pleural effusion. The patient was treated with antibiotics, antifungals, and steroids and finally underwent pericardiotomy. Conclusions: Treatment of CGD patients with recurrent infections and inflammatory lesions is challenging and requires individual decision-making for each patient.

Langerhans Cell Histiocytosis Involving the Thymus and Heart With Simultaneous Thymoma: A Case Report

Langerhans cell histiocytosis (LCH) is a rare disease characterized by clonal expansion of CD1a+/CD207+ cells in lesions. The most frequent sites involved are bone and, less commonly, lymph nodes, lungs, and skin. The thymus or heart is rarely involved with LCH. In this case, we present a 73-year-old woman with a mediastinal mass. Histopathology after thymectomy identified this mass as type AB thymoma; notably, subsequent immunohistochemical tests showed lesions of LCH scattered in the region of thymoma. 18-Fluorodeoxyglucose PET/CT (18-FDG-PET/CT) was performed to make an overall assessment of the extent of this disease, which demonstrated suspicious cardiac involvement of LCH. This report highlights the importance of differentiating abnormalities of the thymus or mediastinal mass from LCH and the necessity of comprehensive evaluation for patients with LCH.

Pericardiocentesis in children: 20-year experience at a tertiary children's hospital

BACKGROUND

Pericardiocentesis is the invasive percutaneous procedure for acute and chronic excessive accumulation of pericardial fluid. There is a paucity of data on the effectiveness and safety of pericardiocentesis in children.

OBJECTIVES

To evaluate the effectiveness and safety of pericardiocentesis and factors associated with acute procedural failure and adverse events.

METHODS

This was a single-centered retrospective study to describe all the children aged ≤20 years who underwent pericardiocentesis. Data on demographics, etiologies of pericardial effusion, and repeat intervention at follow-up were collected.

RESULTS

A total of 127 patients underwent 153 pericardiocentesis. The median age was 6.5 years (1 day-20 years) with weight of 17 kg (0.5-125). Most common etiology was post-pericardiotomy syndrome (n = 56, 44%), followed by infectious (12%), malignant (10%), and iatrogenic (9%). Pericardiocentesis was performed more commonly in the catheterisation laboratory (n = 86, 59%). Concurrent pericardial drain placement was performed in 67 patients (53%). Acute procedural success was 92% (141/153). Repeat intervention was performed in 33 patients (22%). The incidence of adverse events was 4.6% (7/153): hemopericardium requiring emergent surgery (n = 2); hemopericardium with hypotension (n = 2); seizure with anesthesia induction (n = 1); and right ventricle puncture with needle (n = 2). Pericardiocentesis at the bedside had a higher rate of acute procedural failure than that in the catheterisation lab (17 versus 1%, p < 0.01). No identifiable risk factors were associated with adverse events.

CONCLUSIONS

Pericardiocentesis was life-saving in children with its high effectiveness and safety even in urgent situations. Although initial pericardiocentesis was effective, one of five patients required re-intervention for recurrent pericardial effusion.

Kaposiform lymphangiomatosis presenting with a Group A Streptococcus pericardial effusion

A 4-year-old child was transferred to the paediatric intensive care unit with acute respiratory failure following 4 days of fever, nausea and vomiting. Chest X-ray on admission had an enlarged cardiac silhouette and transthoracic echo confirmed a large pericardial effusion. An emergent pericardiocentesis was performed at bedside which drained nearly 1000 mL of purulent fluid. Postdrainage course was complicated by acute systolic and diastolic heart failure, thrombocytopenia and acute renal failure. A chest CT and MRI were concerning for a diffuse mediastinal soft-tissue density, so the patient underwent interventional radiology-guided biopsy complicated by haemorrhage requiring mediastinal exploration and subtotal thymectomy. Histopathology revealed changes consistent with kaposiform lymphangiomatosis and MRI demonstrated involvement of the lumbar spine and right hip. Following a course of intravenous antibiotics, the patient was started on sirolimus and prednisolone and ultimately discharged home.

Clinico-Etiological Profile of Children with Pericardial Effusion in a Tertiary Care Hospital in Eastern India

INTRODUCTION

Pericardial effusion may be due to various causes. With the changing scenario of newer generation antibiotics and robust immunization program our aim is to identify the change, if any, in etiology and disease menifestations.

METHODOLOGY

This is a hospital-based uni-center prospective study with a population of 30 children for a period of 1½ year. Clinico-epidemiological features, investigations, complications and short-term outcome were assessed.

RESULTS

We found 13 (43.33%) patients having mild, 11 (36.67%) had moderate and 6 (20%) had severe pericardial effusion. Cardiac tamponade was present in six cases. Among the study population 9 (30%) patients were diagnosed as having pyogenic pericardial effusion and 8 (26.67%) had tubercular effusion. The predominant symptoms of pericardial effusion in our children were fever and tachycardia (83.33%).Other symptoms at presentation were tachycardia (76.67%), cough (63.33%), chest pain (50%), orthopnea (43.33%) and skin rash (16.67%). Pericardiocentesis was done in 14 cases (46.67%) of which 4 patients (13.33%) required pig tail catheterization.

DISCUSSION

Infectious etiology still remains the primary cause of pericardial effusion in our country. The presenting clinical signs are very much nonspecific and also not so prominent unless hemodynamic compromisation occurs.

CONCLUSION

This study showed that bacterial and tubercular pericardial effusions are still two most prevalent etiological diagnosis in this part of country. Early diagnosis and treatment has good outcome.

Purulent pericardial effusion in children: Experience from a tertiary care center in North India

Background

Purulent pericarditis, if not recognized and managed timely, it can lead to significant morbidity and mortality. There are no guidelines for the management of purulent pericardial effusion in pediatric patients.

Aim

The study describes our experience with the management of 22 patients admitted with a primary diagnosis of purulent pericardial effusion seen over a 7-year period.

Materials and Methods

Hospital records of 22 children admitted to the pediatric intensive care unit with purulent pericardial effusion during January 2012-December 2018 were retrospectively analyzed.

Results

The mean age of presentation was 4.6 years. The most common presentation was fever. History of antecedent trauma was present in 27.27% of patients. Empyema was the most common associated infection. Staphylococcus aureus was the most commonly isolated organism. Out of 22, pericardial drainage was done in 13 patients (59%). Only one of these patients required pericardiectomy later on. Six (27.2%) patients responded to antibiotics alone. Three (13.6%) patients died before any intervention could be planned.

Conclusion

Echocardiography-guided percutaneous pericardiocentesis and pigtail catheter placement are a safe and effective treatment for purulent pericardial effusion. When pericardial drainage is not amenable, close monitoring of the size of effusion by serial echocardiography is required. Small residual pericardial effusion may be managed conservatively.

Infectious and Noninfectious Acute Pericarditis in Children: An 11-Year Experience

Objective

The study was undertaken to determine the etiology, review management, and outcome in children diagnosed with acute pericarditis during 11 years at tertiary pediatric institution.

Methods

Retrospective chart review of children diagnosed between 2004 and 2014. Patients with postsurgical pericardial effusions were excluded.

Results

Thirty-two children were identified (median age 10yr/11mo). Pericardiocentesis was performed in 24/32 (75%) patients. The most common cause of pericarditis was infection in 11/32 (34%), followed by inflammatory disorders in 9 (28%). Purulent pericarditis occurred in 5 children including 4 due to Staphylococcus aureus: 2 were methicillin resistant (MRSA). All patients with purulent pericarditis had concomitant infection including soft tissue, bone, or lung infection; all had pericardial drain placement and 2 required pericardiotomy and mediastinal exploration. Other infections were due to Histoplasma capsulatum (2), Mycoplasma pneumoniae (2), Influenza A (1), and Enterovirus (1). Pericarditis/pericardial effusion was the initial presentation in 4 children with systemic lupus erythematosus including one who presented with tamponade and in 2 children who were diagnosed with systemic onset juvenile inflammatory arthritis. Tumors were diagnosed in 2 patients. Five children had recurrent pericarditis. Systemic antibiotics were used in 21/32 (66%) and prednisone was used in 11/32 (34%) patients.

Conclusion

Infections remain an important cause of pericarditis in children. Purulent pericarditis is most commonly caused by Staphylococcus aureus and is associated with significant morbidity, need of surgical intervention, and prolonged antibiotic therapy. Echocardiography-guided thoracocentesis remains the preferred diagnostic and therapeutic approach. However, pericardiotomy and drainage are needed when appropriate clinical response is not achieved with percutaneous drainage.

Pericardial effusion as a rare complication of a perforated appendicitis

Introduction

Whilst pericardial effusion is a known complication of abdominal pathology, it is rarely reported following ruptured appendicitis and even more rarely requires drainage in that situation. This work has been reported in line with the SCARE criteria (Agha et al., 2016).

Presentation of case

We report a 14-year-old male who developed extensive right hepatorenal and right paracolic abscesses, bilateral pleural effusions and a large pericardial effusion following laparoscopic appendicectomy. Due to the size of the effusion, thoracoscopic pericardotomy was required.

Discussion

Pericardial effusion is a very rare complication of advanced appendicitis despite a demonstrable connection between the retroperitoneum and the mediastinum. Only two cases were reported in our literature search. There is no consensus as to whether percutaneous drainage or pericardiotomy is the treatment of choice.

Conclusion

The report is presented as a reminder of a rare complication of a common general surgical condition.

Novel, Long-axis In-plane Ultrasound-Guided Pericardiocentesis for Postoperative Pericardial Effusion Drainage

Pericardial effusion can be a life-threatening complication in children after cardiac surgery. Percutaneous pericardiocentesis is associated with rare, but serious complications. This retrospective study describes our experience with a novel, long-axis in-plane real-time ultrasound (US)-guided technique for postoperative pericardial effusion drainage in small children. Ten out of sixteen procedures were performed within 14 days of cardiac surgery at a median postoperative day 12 (IQR 2, 99). Median age was 2.7 months (IQR 0.4124) and weight 4.5 kg (IQR 2.5, 41.6). All but one procedure required a single attempt. Fourteen out of sixteen procedures had subxiphoid approach, and two were apical. Median initial drainage was 9 mL/kg (IQR 4.5, 27). Fifty percent of effusions were serous, 25 % chylous, and the remainder bloody. There were no reported complications. This study demonstrates a novel, long-axis pericardiocentesis technique that allows for an easy and safe needle entry into the pericardial space for small children in the early postoperative period.

Pericardial Effusion in Langerhans Cell Histiocytosis: A Case Report

INTRODUCTION

Langerhans cell histiocytosis (LCH) is a proliferative disorder of histiocytes in multiple organs. Langerhans cell histiocytosis involves bones, skin, lung and other organs.

CASE PRESENTATION

This study describes a seven-month-old Iranian girl who presented with skin rash and cervical lymphadenopathy. Langerhans cell histiocytosis was suspected when it was associated with anemia, splenomegaly and lytic bone lesions. A skin biopsy confirmed the diagnosis of Langerhans cell histiocytosis. During hospitalization, the patient looked ill with respiratory distress. A chest X-ray showed a ground glass view, and echocardiography showed moderate pericardial effusion.

CONCLUSIONS

Pericardial effusion was a rare finding in this case of Langerhans cell histiocytosis. Pericardial effusion in Langerhans cell histiocytosis, which is an unusual presentation, should be considered when the patient experiences respiratory distress.