A 49-year-old male smoker of 12 cigarettes a day and former drinker for 3 years.
She came to the emergency department due to progressive dyspnea on the previous days to minimal exertion, accompanied by edema, dizziness and syncope, with no accompanying chest pain or orthopnea.
A relevant history included infectious endocarditis in a myxoid mitral valve, with perforation and severe mitral regurgitation. The patient was initially treated with antibiotics and later replaced with mitral valve replacement with complicated mechanical valve replacement.
She was discharged 10 days before the current admission to treatment with acenocoumarol, bisoprolol, furosemide and amiodarone.
The physical examination revealed a regular general condition, hypotension (90 mmHg), jugular venous distension and hepatomegaly of 3 fingers.
The laboratory tests showed a significant increase in transaminase levels (AST: 5,550 U/L; ALT: 3,826 U/L) and LDH (10,375 U/L), with slightly elevated bilirubin levels (2 mg/dL).
He also had anemia (Hb: 9.2 g/dL), impaired renal function (Cr: 1.76 mg/dL; urea 88 mg/dL) and an I.N.R. of 9.86.
Serology for HAV, HBV, HCV, HIV, EBV, CMV and autoimmunity were negative.
The intake of drugs and other hepatotoxic products was discarded.
The electrocardiogram showed no changes of interest and ultrasound showed marked hepatomegaly with diffuse alteration of echogenicity in relation to steatosis, with normal hepatic vascular study.
suspecting a possible cardiac origin of the clinical picture, an echocardiogram was performed which confirmed the presence of massive pericardial effusion, predominantly in the right ventricular free wall, where it reached 60 mm thick, and in the left ventricle with 29 mm thick.
The right ventricle as well as the initial portion of the pulmonary artery appeared completely collapsed, data of severe echocardiographic taping.
1.
a The mild patient was referred to the Coronary Care Unit where diagnostic and evacuating pericardiocentesis was performed using an anterior approach (3o intercostal space for apical sequestration) located with 600 cc of hemorrhagic fluid collection.
Samples were sent for biochemistry, microbiology and cytology, confirming a leak with a hematocrit higher than plasma, being the microbiological study and cytology normal.
At the same time, corticosteroid treatment was initiated with good clinical response.
Analytically, normalization of creatinine levels (0.72 mg/dL) and progressive decrease in transaminase levels (568 U/L; ALT: 227 U/L) were observed.
Before discharge, a control echocardiogram showed mild pericardial effusion of fibrinous aspect, loculated, asymmetrical distribution, predominantly located anteriorly and apex of the right ventricle, with no data of hemodynamic compromise.
Because of the good clinical and analytical evolution, liver biopsy was not necessary and the patient was diagnosed with ischemic hepatitis due to low cost situation in relation to cardiac taping secondary to postpericardiotomy syndrome with hemorrhagic transformation.
