Intensivist Mercy Catholic Medical Center, United States
Introduction: A compelling case of a young man with cardiac tamponade led to an unexpected metastatic gastric cancer diagnosis. When confronted with unexplained pericardial effusion, physicians must remain vigilant in exploring hidden malignancies.
Description: A 35-year-old Spanish-speaking man without any previous history presented with dyspnea, chronic epigastric pain, nausea, diarrhea, early satiety, and unintentional weight loss. He also had orthopnea and leg swelling. On exam, he had JVD and grade 3 pitting pedal edema. A routine CT scan performed in the ED showed marked gastric wall thickening/edema, mucosal hyperenhancement, and perigastric lymph nodes without any major lung findings except for peribronchial thickening. A stat bedside echo showed a large volume of pericardial fluid with a likelihood of tamponade. Due to the risk of impending cardiac tamponade and obstructive shock, pericardiocentesis was done by removing 870 cc of straw-colored fluid with drain placement, and the patient was monitored in ICU. Endoscopy revealed an ulcerated mass in the gastric antrum which was H.pylori associated poorly differentiated signet ring cells adenocarcinoma with atypical B cells denoting metastasis.
Discussion: Pericardial effusion in abdominal malignancy is rare and often detected at an advanced stage. The primary mechanism is metastasis through hematologic/lymphatic spread to the pericardium leading to fluid accumulation. A prompt pericardial fluid removal is crucial to prevent hemodynamic instability. A study reported 33% of patients with large pericardial effusion had underlying neoplasm, with only 2 cases(1%) being GI in origin, indicating its extreme rarity, with positive cytology in 51%. Cytology is positive in malignant effusion with a variable sensitivity of 54-90%. Except for cases of traumatic injury, hemorrhagic pericardial effusion highly indicates malignancy, along with possible association of paroxysmal atrial fibrillation. Patients with large/recurrent pericardial effusion or refractory to anti-inflammatory treatment should undergo a comprehensive workup to detect hidden malignancy. This case emphasizes the need for vigilance, as a thorough investigation revealed metastatic gastric signet ring cell carcinoma despite the patient's young age and absence of apparent secondary causes.
