Introduction: Pericardial effusions can have various etiologies, including infectious, autoimmune, drug induced, endocrinologic, among others. Cardiac tamponade occurs when large effusions compress the heart and can lead to obstructive shock.
Case Description: A 48-year-old female with a history of hypothyroidism and pituitary adenoma resection presented with subjective fevers and generalized weakness for the past 5 days. She was lethargic with muffled heart sounds on exam. Vitals showed a heart rate 95 beats per minute, blood pressure 63/51, respiratory rate 18 breaths per minute, with normal temperature. Labs on admission were significant for white blood cell count of 11,500/L, hemoglobin 10.8 g/dL, sodium of 126 mmol/L and lactate 3.7. Electrocardiogram showed normal sinus rhythm with nonspecific ST and T wave changes. Further workup was consistent with secondary adrenal insufficiency (AI). Chest computed tomography demonstrated ground glass opacities with cephalization of the pulmonary vessels, bilateral pleural effusions and a large pericardial effusion. Transthoracic echocardiogram showed the large pericardial effusion with moderate right atrial collapse.
She underwent emergent pericardial window with drainage of 700 mL of serous dark fluid. Blood cultures were negative, and fluid culture grew Enterococcus faecalis. She received empiric antibiotics on admission, as well as intravenous fluids and parenteral hydrocortisone with subsequent stabilization of blood pressure and electrolyte abnormalities.
Discussion: This is a unique case of cardiac tamponade in a patient who had adrenal insufficiency and suspected sepsis on admission. Cardiac tamponade can mimic septic shock, and early recognition of it is critical, as treatment is emergent pericardiocentesis. A few case reports have documented this peculiar association between AI and cardiac tamponade, and AI is hypothesized to increase the risk of small or moderate pericardial effusions progressing to life threatening tamponade.