Clinical history and current disease
27-year-old male patient with a history of nephrotic syndrome due to focal and segmental hyalinosis diagnosed at 4 years of age. He was treated with peritoneal dialysis until 1998, when he was transplanted. In 2007 he presented chronic rejection and recurrence of hyalinosis; therefore, in 2008 he underwent embolisation of the renal graft and restarted peritoneal dialysis again until the present day. Severe pericardial effusion in 2008 of uraemic aetiology. One year ago total thyroidectomy for papillary carcinoma of follicular pattern, with foci in both thyroid lobes and micrometastasis in one lymph node of the 23 isolated lymph nodes; she subsequently received treatment with radioactive iodine.
Clinical picture of 48 hours of evolution consisting of progressive dyspnoea and asthenia. Physical examination on admission: patient alert, conscious, oriented, tachypneic and intolerant to decubitus. BP: 85/46 HR: 128 bpm FR: 28 Afebrile SaO2: 92% with nasal goggles. Head and neck: jugular ingurgitation at 45o. Cardiac auscultation rhythmic and regular, with diminished intensity. Lung fields well ventilated, without over-aggregate sounds. Abdomen soft, depressible, not painful. Extremities with present and symmetrical pulses, grade I/IV malleolar oedema.

Complementary tests
- CBC: leukocytes 6,600 with adequate differential count, Hb 8.7, haematocrit 26%, MCV 79.5, MCH 26.6, platelets 214,000, Act. PT 71.7%, aTTP 30.42, glucose 109 mg/dl, urea 74, creatinine 6.8, total protein 4.2. Ions and cardiac enzymes within normal limits.
- ECG: sinus tachycardia at 128 bpm, decreased voltages.
- Chest X-ray: significant increase in cardiothoracic index. Right costophrenic sinus pinched, left costophrenic sinus not visible by the cardiac silhouette.
- TT echocardiography: pericardial effusion with maximum diameters in end-diastole of up to 4 cm and signs of haemodynamic compromise.

Clinical evolution
The patient was admitted to the Intensive Care Unit and evacuating pericardiocentesis was performed after superficial sedation with echo-guided propofol. Given the high possibility of pericardial effusion of probable uraemic aetiology, it was notable that after uncomplicated puncture the drainage fluid had a significant haematic component, so it was decided to perform an echocardiographic test with agitated serum through a catheter needle to check the correct location; bubbles were clearly observed in the pericardial space. After drainage of 600 cc, an increase in blood pressure was observed, but he remained tachycardic and presented desaturation requiring O2 supply with a reservoir. Chest X-ray after puncture showed complete veiling of the left hemithorax, in addition to an evident interstitial pattern in the right hemithorax compared to the previous X-ray.
An urgent chest CT scan was requested with findings of opacification of the left upper lobe with air bronchogram suggestive of atelectasis, alveolar oedema and moderate bilateral pleural effusion (31 mm thick in the right base and 25 mm in the left base) which surrounds the atelectasized parenchyma at the level of the left apex; severe circumferential pericardial effusion which at the left posterolateral level reaches up to 5 cm in thickness; pericardial catheter located anterior to the right ventricular outflow tract. The patient was treated with non-invasive mechanical ventilation and diuretics, obtaining a rapid clinical response with progressive re-expansion of the left upper lobe and clear improvement of the radiological signs of heart failure, until respiratory stability and O2 saturations of 99% were obtained with nasal goggles. Total pericardial drainage was 1800 cc. The fluid study showed red blood cells of 800000/mm3 and other parameters within normal limits, with no bacteria in the gram, negative cultures for aerobes and anaerobes; and negative for malignant cells in the pathological anatomy study.

Diagnosis
- Severe pericardial effusion with signs of haemodynamic compromise in a patient with chronic kidney disease on peritoneal dialysis
- Alveolar oedema and pleural effusion ex vacuo secondary to pericardiocentesis
- Left upper lobe atelectasis secondary to sedation
