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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Approximately 50% of CML patients are asymptomatic at presentation Pericardial effusion in the chronic phase of CML is a rare occurrence and association with tamponade is extremely rare CASE PRESENTATION: A 69 y/o female with a recent diagnosis of BCR/ABL+ chronic myeloid leukemia, T2DM, HTN, and CAD who presented to the ED complaining of shortness of breath (SOB) The patient reports her shortness of breath started worsening in the last couple of days prior to admission Denied any orthopnea or PND Endorsed positional dizziness, palpitation, poor oral intake, and poor appetite, easy bruising and episodes of blurry vision Physical examination: Heart rate 95, BP 89/55 Hypoxic on 4L nasal cannula Lung exam revealed crackles with decreased breath sounds, muffled heart sounds, and no murmurs Labs: Hemoglobin of 7 9 g/dL, hematocrit of 25 6 %, platelets 379k m/mm3, WBCs 105 2k m/mm3 and Peripheral smear (Figure 1) showed Neutrophils 46%, Bands 10%, lymphocyte 10 %, Monocyte 4%, Metamyelocyte 21%, Myelocyte 9%, blasts 1% CMP showed: Na 134 mmol/L, K 7 3 mmol/L, Bicarb 19 mmol/L, BUN 103 mg/dL, Cr 3 4 mg/dL, Glucose 208 mg/dL, AST 17 U/L, ALT12 U/L, Uric acid 15 2 mg/dL ProBNP 1135 pg/mL,Trop <0 015 ng/mL, and procalcitonin 1 3 ng/mL COVID-19 screen is negative Blood culture shows no growth after five days Immunoglobulins were within normal limits RF and ANA screen is negative P-ANCA and C-ANCA antibodies are negative C3 and C4 were within normal limits CXR (Figure 2) showed air space disease, left side pleural effusion, and waterbottle-shaped heart concerning for pericardial effusion Transthoracic echocardiography shows a large pericardial effusion of 2 cm circumferentially surrounding the heart with focal strands (Figure 3) Bedside Pericardiocentesis performed and 900cc of frank bloody fluid removed, and a drain was left in place for subsequent removal of 400cc on day 2 and 250 cc on day 3 Pericardial fluids analysis: negative gram stain/culture, bloody appearance, 2,300,000 RBCs, 64,420 WBCs with PMNs 94%, Lymphocyte 2%, and Monocyte 2% Pericardial cytology showed infiltration by CML The patient hemodynamics improved after pericardiocentesis, and a total of 1550 cc of bloody pericardial fluid was removed Tyrosine kinase inhibitors were not started due to prolonged QTc of 540ms DISCUSSION: The proposed mechanisms of pericardial effusions in patients with CML include leukemic infiltration into the pericardium, extramedullary hemopoiesis, obstruction of pericardial capillaries, infiltration of interstitial tissue by leukemic cells causing increased capillary permeability, and non-malignant etiologies, including infection and hypoproteinemia CONCLUSIONS: CML is a rare cause of the pericardial effusion Urgent pericardiocentesis may be indicated in a hemodynamically unstable patient Routine echo recommended before starting TKIs, to rule out pericardial effusion Reference #1: 1 Lam KY, Dickens P, and Chan AC Tumors of the heart A 20-year experience with a review of 12,485 consecutive autopsies Arch Pathol Lab Med 1993;117(10):1027 PMID: 8215825 Reference #2: 2 Imazio M, Colopi M, and De Ferrari GM Pericardial diseases in patients with cancer: contemporary prevalence, management and outcomes Heart 2020;106(8):569 Epub 2020 Jan 24 PMID: 31980441 Reference #3: 3 Ben-Horin S, Bank I Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis Medicine (Baltimore) 2006;85(1):49 PMID: 16523053 DISCLOSURES: No relevant relationships by Ameenjamal Ahmed, source=Web Response No relevant relationships by David Dexter, source=Admin input No relevant relationships by Salem Gaballa, source=Web Response No relevant relationships by Kyaw Hlaing, source=Web Response No relevant relationships by Safa Moursy, source=Web Response No relevant relationships by Brijesh Patel, source=Web Response No relevant relationships by Austin Rallis, source=Web Response
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