Common cause of Pericardial Effusion : Tuberculosis
CLINICAL FEATURES:PERICARDIAL EFFUSION
- Heaviness of the precordium.
- Pain over the precordium due to stretching of parietal pericardium, aggravated by swallowing or body bending.
- Dry cough.
- Low grade temperature.
- Pain in the right hypochondriac region due to hepatomegaly.
- There may be no symptom if the effusion is small or develops slowly.
Signs are usually detected when a minimum amount of 500 cc of fluid accumulates in the pericardial sac. Normally it contains 5-20 cc of serous fluid. PERICARDIAL EFFUSION
Patient may be dyspnoeic, may be in propped up position. Sometimes patient may assume a ‘Mohammedan prayer position. Pulse rate is high, volume is low, typical pulsus paradoxus may be present when there is cardiac tamponade and during inspiration systolic pressure is dropped by 10 mm of Hg or more. BP is usually low. Pulse pressure is also low. Cyanosis may be present and is more often peripheral type. Neck veins are engorged and non-pulsatile. During inspiration the engorgement is aggravated (Kussmaul’s sign or venous pulsus paradoxus). JVP is high and increased during inspiration (Friedreich’s sign). Oedema may be present, BP is low. PERICARDIAL EFFUSION
Precordium is bulged but quiet. The play of left leaflet of diaphragm may not be seen (Hoover’s diaphragmatic sign). Apical impulse is neither visible nor palpable. Increased cardiac dullness on percussion which may assume an oval shape in supine position and triangular in erect posture. If apex beat is felt, it will be found within the outer border of cardiac dullness which is a diagnostic clinical sign. Sternum is dull particularly in its lower part (Dressler’s sign). Left second interspace is dull. PERICARDIAL EFFUSION
Heart sounds are either muffled or distant. Pericardial knock sound may be audible. Sometimes pericardial friction sound may also be heard.
At the inferior angle of left scapula, there is increased vocal fremitus, dull note on percussion and bronchial breath sound due to collapsed lung by the pressure of pericardial fluid or due to associated pleural effusion (Ewart Bamberger’s or Pins sign). No moist sound is present as lung is not congested but may be present due to primary pathology in the lung.
Liver is palpable (particularly the left lobe) and tender due to congestion of hepatic veins. For this epigastric fullness may be present (Auenbrugger’s sign).
SPECIAL INVESTIGATIONS: PERICARDIAL EFFUSION
- Fluoroscopy shows non-pulsatile enlarged cardiac shadow.
- X-ray of the chest (PA) shows:
- a) Enlarged and pear-shaped cardiac shadow. Gradual changes in the size of the cardiac shadow may be seen in serial skiagrams.
- b) Altered cardio-thoracic ratio.
- c) Obliteration of cardiac landmarks on the right and left borders of the heart.
- d) More acute right cardio-phrenic angle (Rotch’s sign).
- e) Oligaemic lung fields.
- f) Left-sided pleural effusion is common.
- ECG shows low voltage with T wave changes. In presence or tamponade electrical alternans may be present (partial or total).
- Cardiac catheter pushed upto the lateral wall of right atrium will determine the lateral border of heart shadow but shadow beyond the catheter tip is due to effusion.
- Echocardiography is most important investigation. It shows an echo-free space between the anterior wall of the right ventricle and the chest walll as well as posterior wall of the left ventricle and the lung in presence of very small effusion (more than 15 to 20 cc). Fibrin strands can be seen in the echo-free space as well as abnormal swinging of the heart.
- Pericardial paracentesis shows presence of fluid, the characteristic of which depends on its aetiology.
- Angiocardiography may also demonstrate the presence of pericardial fluid.
- Radionuclide cardiac scanning als0 reveals shadow of pericardial fluid outside the cardiac chambers.
- CT and MRI will also demonstrate thickened pericardium and effusion.
Cardiac Tamponade : PERICARDIAL EFFUSION
This is a condition of severe cardiac compression by rapidly accumulating fluid in the pericardial sac or by constrictive pericarditis. This is characterized by marked congestion of neck veins, very low volume pulse, low blood pressure and tachycardia. Pulsus paradoxus and electrical alternans are usually present. Clinically this condition resembles shock. This demands immediate pericardial paracentesis. Very prominent jugular veins, severe cardiac compression and markedly low BP constitute Beck’s Triad.