PERICARDIUM EFFUSION IN A 44 YEAR OLD MALE PATIENT AT RSUD CIAWI

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ABSTRACT
Pericardial effusion occurs due to the accumulation of abnormal fluid in the pericardial space, the
fluid can be in the form of transudate, exudate, pyeopericardium, or hemopericardium. In normal
people, the sac usually stores 15 to 50 mL of serous fluid. Pericardial effusion can occur due to
several causes, such as infection, inflammatory process, malignancy, trauma, idiopathic, or due
to other heart diseases. Pericardial effusion is most often caused by Mycobacterium Tuberculosis
infection. Compression of the heart will cause venous congestion and reduce left ventricular
diastolic filling. In the final stage, there will be a decrease in blood pressure and cardiac output.
When hypotension, jugular venous distension, and dull heart sounds (Beck's triad) are found, the
patient can be said to be experiencing cardiac tamponade. Patients with cardiac tamponade also
show other signs associated with cardiogenic shock. A 44 year old male patient complained of
pain in the stomach accompanied by heat, tightness and nausea since one week before entering
the hospital. Apart from that, after several days of treatment, the patient also felt tightness and
pain in the left chest like a stabbing sensation that spread to the back and when the patient placed
his hands above his head and when the patient lay on his left side the complaints became worse.
The patient has a history of stabbing-like chest pain that has been intermittent for the past year
and has become worse for the past month. Previous medical history is unknown and history of
smoking is 1 – 2 packs per day. Physical examination of the heart revealed cardiomegaly,
electrocardiogram examination revealed late onset STEMI and RBBB, echocardiography
examination revealed percardial fluid around the heart with an EF of 65%. Pericardiocentesis
was performed on the patient and a total of 2,311 cc of fluid was obtained. The patient's
condition improved after treatment at RSUD Ciawi.

Keywords: cardiac tamponade, pericardial effusion, STEMI

BACKGROUND
Pericardial effusion occurs due to the accumulation of abnormal fluid in the pericardial space, the
fluid can be in the form of transudate, exudate, pyopericardium, or hemopericardium. 1-9 In
normal people, the sac usually stores 15 to 50 mL of serous fluid. 4-6 Pericardial effusion is the
result of the clinical course from a disease, it can occur acutely, subacutely and chronically and
can even cause cardiac temponade.5-9 Pericardial effusion can occur due to several causes, such
as infection, inflammatory process, malignancy, trauma, idiopathic, or due to other heart
diseases.9-12 Pericardial effusion is most often caused by Mycobacterium Tuberculosis infection. 8
Compression of the heart will cause venous congestion and reduce left ventricular diastolic
filling. In the final stage, there will be a decrease in blood pressure and cardiac output. 10-12 When
hypotension, jugular venous distension, and dull heart sounds (Beck's triad) are found, the
patient can be said to be experiencing cardiac tamponade. 12 Patients with cardiac tamponade also
show other signs associated with cardiogenic shock.12
CASE PRESENTATION
A 44 year old man came to the Emergency Room at RSUD Ciawi with heartburn, burning
in his chest, tight stomach and nausea since a week ago. Last bowel movement four days ago.
The patient has a history of gastric pain. Since the last year, the patient has often felt pain in the
left chest like being stabbed, the chest pain is felt suddenly when the patient is resting or doing
activities, the chest pain occurs for only a few seconds with a frequency of 1 - 2 times a month.
Chest pain does not interfere with activities so the patient ignores it. Since the last month,
stabbing chest pain has appeared more frequently and has spread to the back, appearing 2-3 times
a week, but the patient has not sought treatment. The patient had no known history of
hypertension and dyslipidemia. Denied complaints such as coughing, fever, getting tired easily
when climbing stairs, palpitations, swollen feet and a history of trauma. There is no known
history of hypertension, diabetes mellitus, dyslipidemia, no history of heart disease, no history of
pulmonary tuberculosis and no history of trauma. The patient has had a smoking habit since
twenty years ago of 1 – 2 packs per day.
The results of the physical examination were blood pressure 140/90 mmHg, pulse 70
times per minute, oxygen saturation 98% with a nasal cannula of 3 liters per minute. Cardiac
examination revealed cardiomegaly and abdominal examination revealed epigastric tenderness
and hepatomegaly. Significant supporting examinations were hemoglobin 10.7 g/dL, hematocrit
31.3%, leukocytes 11,500/uL, thrombosis 289,000/uL, sodium 133 mRq/L, potassium 3.5
mEq/L, chloride 105 mEq/L, SGOT 398 U/L, SGPT 1,019 U/L. HBsAg and HIV tests were non-
reactive, anti-HCV was negative. On ECG examination, late onset inferior STEMI was found.
The working diagnoses used were abdominal pain, hepatomegaly and late onset inferior STEMI.
In the emergency room, the patient was given 0.9% NaCl fluid therapy, oxygen supplementation,
omeprazole, sucralfate, ondansetron, nophargen and curcuma. The patient was then hospitalized.

Figure 1. Results of the patient's electrocardiogram on 14th June 2024 (at 02.44 PM)
 Figure 1. Results of the patient's electrocardiogram on 14th June 2024 (at 04.27 PM)

Figure 3. Results of abdominal ultrasound Figure 4. Photo results of BNO 3 positions

on 19th June 2024 on 19th Juni 2024

On the fifth day of treatment (19 June 2024), the patient complained of dizziness,
shortness of breath at night and chest pain. Complaints of abdominal pain improved.
Investigations for total cholesterol 153 mg/dL, HDL 27 mg/dL, LDL 98 mg/dL, Triglycerides 86
mg/dL, Albumin 3.25 g/dL, GDP 94 mg/dL, SGOT 227 U/L and SGPT 779 U /L. ECG
examination shows late onset inferior STEMI and RBBB. On abdominal ultrasound, the
impression was Cholecystitis, abscites with bilateral pleural effusion, no abnormalities were seen
in the liver, pancreas, spleen, kidneys and bladder. In the BNO photo 3 is the position of the Ileus
impression. The working diagnosis used was late onset STEMI, CHF, suspected congestive liver.
Previous therapy was continued and additional clopidogret 4 tablets, Aspilet 2 tablets, Lovenox
2x0.6cc subcutaneously were given. Then treatment is continued by a heart specialist.

On the seventh day of treatment (21 June 2024), the patient was admitted to the HCU and
underwent an echocardiography examination. The results of the echo examination showed
pericardial fluid around the heart, EF 65%. The working diagnosis was Recent inferior STEMI
10 days, AHF on ACS and PE without signs of tamponade. The patient received additional
therapy with oral colcihine 2x0.5mg, simvastatin 1x20mg, ISDN 5mg SL, intravenous Lasix
3x40mg. Then pericardiocentesis was carried out and a pig tail was placed on the patient and
630cc of fluid was obtained. After the procedure the patient felt short of breath reduced. Routine
blood tests were carried out after pericardiocentesis, hemoglobin 10.8 g/dL, hematocrit 31.1%,
leukocytes 11,700/uL, platelets 359,000/uL.

a.Echo (+) EF 65% c.Setelah pericardiosintesis

b.Sebelum pericardiosintesis

Figure 5. a. Echocardiography examination, b. Before pericardiocentesis c. After

pericardiocentesis

Figure 6. Pericardiocentesis action

Day nine of treatment (23 June 2024). The patient complained of severe shortness of
breath and a burning sensation in the chest. On examination, blood pressure was 84/46 mmHg,
pulse 140 times per minute, respiration 35 times per minute, oxygen saturation 96% with a nasal
cannula of 3 liters per minute. Physical examination was within normal limits. Laboratory
examination showed hemoglobin 10 g/dL, hematocrit 29.5%, leukocytes 16,000/uL, thrombosis
479,000/uL, sodium 131 meq/L, potassium 2.6 meq/L, chloride 94 meq/L. Working diagnosis
Recent inferior STEMI, AHF in ACS, PE without signs of tamponade, suspected cardiogenic
shock. The patient was given 500 cc 0.9% Nacl loading, and was started to be given
norepinephrine 0.1 mcg/kgBW/minute.

Figure 7. Patient electrocardiogram results on 23th June 2024

Tenth day of treatment (24 June 2024). The patient had a repeat blood test, hemoglobin
8.5d/dL, hematocrit 26.1%, leukocytes 17,000/uL, platelets 503,000/uL. The results of the
troponin T examination were 53ng/mL. Working diagnosis of inferior STEMI, post
pericardiocentesis pericardial effusion, anemia, and hypokalemia. Therapy was continued and
added recolfar 1x0.5mg, furosemide 2x1 ampoule, 250cc blood transfusion and PCI would be
carried out when the condition was stable.
Twelfth day of treatment (26 June 2024). The patient said he was not short of breath.
Blood pressure examination was 122/85 mmHg and pulse rate 104 times per minute using
dobutamine 3 mcg/kgbb/minute. Electrocardiographic examination showed right ventricular
hypertrophy, late onset inferior STEMI and RBBB. The patient's repeat blood examination,
hemoglobin 9.2 g/dL, hematocrit 28.1%, leukocytes 18,100/uL, platelets 438,000/uL. Working
diagnosis of AHF in ACS EF 31%, Recent inferior STEMI, Post tapping cardiac tamponade and
left pleural effusion. Therapy is still continuing with the dobutamine weaning plan until off,
2x40mg furosemide injection and fluid balance -1000cc/24 hours.
 Gambar 8. Hasil elektrokardiogram pasien pada tanggal 26 Juni 2024
Thirteenth day of treatment (27 June 2024). Patients complain of tightness and chest
pain. Blood pressure examination was 103/76 mmHg and pulse rate was 86 beats per minute.
Electrocardiographic examination showed late onset inferior STEMI and RBBB. The patient's
repeat blood examination, hemoglobin 8.8 g/dL, hematocrit 26.7%, leukocytes 22,000/uL,
platelets 483,000/uL, troponin 28 ng/nL.

Figure 9. Patient electrocardiogram results on 27th June 2024

Fourteenth day of treatment (28 June 2024). Pig tail was removed from the patient and a
total of 2,311cc of post pericardiocentesis fluid was obtained. On electrocardiography
examination, late onset inferior STEMI and RBBB were obtained.

Figure 10. Patient electrocardiogram results on 28 June 2024

Fifteenth day of treatment (29 June 2024). The patient said there were no complaints, his
condition was good. On examination, blood pressure was 90/60 mmHg, pulse rate was 82 beats
per minute. On cardiopulmonary auscultation, no rales or wheezing were found. Working
diagnosis of recent inferior STEMI, cardiac tamponade post tapping pericardium and CAP. An
echo evaluation was carried out and therapy was given with 1x1.25 mg concor and 2x2.5 mg
nitrocaf. The patient's condition was good and stable so he was allowed to be outpatient.
CONCLUSION
The patient with a working diagnosis of recent inferior STEMI and pericardial effusion
complained of pain in the stomach accompanied by heat, tightness and nausea since one week
before entering the hospital. Apart from that, after several days of treatment, the patient also felt
tightness and pain in the left chest like a stabbing sensation that spread to the back and when the
patient placed his hands above his head and when the patient lay on his left side the complaints
became worse. Since one year ago, the patient has also felt pain in the chest like being stabbed,
but only for a few seconds and then disappears with a frequency of 1 – 2 times a month. The
patient never ignored or sought treatment for his complaints of chest pain. Since one month chest
pain accompanied by pain radiating to the back has become more frequent with a frequency of 2
– 3 times a week. There is no known history of hypertension, diabetes mellitus, dyslipidemia, no
history of heart disease, no history of pulmonary tuberculosis and no history of trauma. The
patient has had a smoking habit since twenty years ago of 1 – 2 packs per day. Physical
examination of the heart revealed cardiomegaly, electrocardiogram examination revealed late
onset STEMI and RBBB, echocardiography examination revealed percardial fluid around the
heart with an EF of 65%. Pericardiocentesis was performed on the patient and a total of 2,311 cc
of fluid was obtained. The patient's condition improved after treatment at RSUD Ciawi.

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