Unusual presentation of pericardial effusion
64-years-old male, chronic alcoholic since last 30 years and ex-smoker (9 pack years), hypertensive on tab amlodipine 2.5 mg od, presented with a 15 days history of cough associated with mucopurulent expectoration and 3-4 episodes per day of unconsciousness associated with cough since the last 2 days The syncopal episodes lasted for 30 seconds to 1 minute with complete recovery after syncope. During one of the syncopal event, he had a fall, which was associated with scalp injury and epistaxis. No vomiting or seizure was reported during the syncopal event. On admission to hospital, he was normotensive, with a pulse rate of 80/min, with a blood pressure of 110/70 mm of hg. On physical examination, he was found to have palpable right supraclavicular lymph node, which was firm to hard, mobile, and non-tender, and JVP was not raised. Breath sounds were decreased in the lower right hemithorax. The hemoglobin level was 13.4 g/dL, leukocyte count of 11000/cmm. The chest x-ray showed right hilar prominence. A high-resolution contrast-enhanced CT scan of the chest was performed, which showed a concentric thickening of tracheobronchial tree, which was more pronounced in the lower lobe of the right lung with distal consolidation and ground-glass opacities. Moderate bilateral pleural effusions and a moderate pericardial effusion were also seen. Fine needle aspiration of right supraclavicular lymph node showed Metastatic Non-Small Cell Carcinoma.\nTransthoracic echocardiography revealed moderate pericardial effusion with 2 cm of fluid behind the posterior wall of the left ventricle [], no diastolic collapse of the ventricles. The IVC did not collapse with respiration. The heart valves and left ventricular systolic function were normal, with an ejection fraction of 60%.\nAn episode of cough syncope was witnessed in the ICU, during which the systolic blood pressure showed a 60 mm drop, along with tachycardia. After recovery from this episode, an echocardiogram was repeated, which showed evidence of tamponade in the form of early diastolic collapse of right ventricle, late diastolic right atrial inversion with abnormal movement of the septum when the patient coughed, which disappeared when he stopped coughing.\nPericardiocentesis was performed, 500 ml of hemorrhagic fluid was drained, and a pigtail catheter was placed for further drainage of fluid. After drainage of the pericardial fluid, the patient did not experience any further episodes of cough syncope.\nThe pericardial fluid too showed numerous mesothelial cells and clusters of atypical cells, which were identified as metastatic Non-Small Cell Carcinoma.