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Mechanical Cardiac Tamponade as
an Initial Presentation of Malignant
Lymphoma: Case Report
Bouziane M*, Kherraf A, Abdulhakeem M, Arous S, Nouamou I, Benouna G, Drighil A, Azzouzi L and Habbal R
Department of Cardiology, Ibn Rochd University hospital of Casablanca, Morocco
Submission: July 26, 2020; Published: August 14, 2020
*Corresponding author: Maha Bouziane, Department of Cardiology, P37 Ibn Rochd University hospital of Casablanca, Quartier des Hôpitaux, Casablanca, Morocco
How to cite this article:Bouziane M, Abdulhakeem M, Kherraf A, Arous S, Benouna M, et al. Mechanical Cardiac Tamponade as an Initial Presentation of
Malignant Lymphoma: Case Report. J Cardiol & Cardiovasc Ther. 2020; 16(3): 555938. DOI: 10.19080/JOCCT.2020.16.555938
Cardiac tamponade results from an accumulation of pericardial fluid under pressure, leading to impaired cardiac filling and haemodynamic compromise. In malignant lymphoma, cardiac and pericardial involvement, even though relatively uncommon, can be one early manifestations of this neoplastic disease. We describe a case of a 21 year old female with no medical history, whose first presentation for mediastinal lymphoma was a mechanical cardiac tamponade.
Cardiac tamponade is a life-threatening setting due to slow or rapid pericardial build-up of fluid with subsequent compression of the heart. One of the many causes of it is neoplastic diseases, such as lymphomas.
There are several explanations regarding pericardial effusion in lymphoma. It may be due to lymphatic and blood spread. Effusion may be caused by an obstacle of the lymphatic and venous drainage of pericardial fluid. It may also not involve the pericardium. The lymphatic channels from visceral pericardium have drainage at the aortic root. This drainage spot can be blocked either by malignant deposits or via compression due to enlarged lymph nodes .
Malignant lymphoma can arise in or spread to the mediastinum. Mediastinal lymphadenopathy due to lymphoma may present early due to rapid growth of the tumor and compression caused by it .
The objective of this observation is to report the case of a mechanical tamponade caused by a compression of the right heart chambers by a probable mediastinal lymphoma.
We report the case of a 21-year-old female patient, without any known medical history, who was admitted to the emergency
department for a stage III to IV dyspnea of NYHA and right chest
pain that had been progressing for 3 weeks.
On clinical examination, her blood pressure was 100/60 mmhg, heart rate was 96 beats/minute, with muffled heart sounds, elevated jugular veins pressure, signs of right pleural effusion and a supraclavicular lymphadenopathy.
The electrocardiogram revealed a sinus tachycardia, a decreased electrocardiographic voltage without electrical alternans. The chest X-ray showed total opacification of the right hemithorax with an enlarged cardiac silhouette (Figure 1).
A thoracic CT scan was performed showing a large right mediastinal mass measuring 174x40x86 mm, causing an upper right segmental collapse and significant compression of the cardiac chambers, as well as a moderate pleural effusion (Figure 2 & 3). The transthoracic echocardiography objectified a 35mm pericardial effusion over the right heart chambers, with a preserved LV function (Figure 4).
Routine blood tests showed a hypochromic microcytic anemia
(Hemoglobin at 9.7g/dl), normal white blood cell count (9800),
elevated platelets (578000), normal prothrombin levels at 82%,
and elevated fibrinogen at 6.4g/l; and abnormal hepatic enzymes
with ALT at 110 IU/l and AST at 60 IU/l. Serological tests for
hepatitis, HIV and syphilis were negative. A thoracentesis was
done revealing an exudate pleural fluid. A bone marrow biopsy
was also performed objectifying a lymphoid infiltration and
overactive bone marrow.
Multiple transparietal pleural biopsies and a biopsy of
the supraclavicular lymphadenopathy were non- conclusive
(inflammation, necrosis and lymphadenitis). After discussing
the patient’s case by a multidisciplinary team, lymphoma was
considered the most likely diagnosis and chemotherapy wasn’t
possible in her case. A trial of corticosteroid therapy was
started, with a twice daily 120mg dose of methylprednisolone,
allowing a relative decompression of the heart chambers. The
patient was referred for surgical pericardiectomy and diagnostic
All diseases that can involve the pericardium can cause
a pericardial effusion. Therefore, idiopathic pericarditis and
numerous infections, neoplasms, autoimmune diseases, radiation,
post-ST segment elevation myocardial infarction (STEMI)
pericarditis, and noxious substances, for example, blood, may be
responsible. Some studies have suggested that as many as 20%
of pericardial effusions without an obvious cause after routine
evaluation constitute the initial manifestation of a cancer .
Indeed, Perek B et al concluded in their study of 81 previously
healthy patients, which cardiac tamponade was the main symptom
of cancer, especially of the lungs .
Mediastinal masses are rare and are often found incidentally;
however, finding the exact etiology of the tumor is relatively
difficult. The most common tumors are: small cell carcinoma
(40%), lymphoma (20%), thymomas (16%). The definitive
diagnosis is histological .
Cardiac presentaions from lymphomas can be primary or
secondary. Primary cardiac lymphoma concerns the heart or
pericardium and is considered a rare presentation of lympohmas,
accounting for less than 1% of all extranodal localization of these
tumors. However, masses involving other sites, such as mediastinal
lymphadenopathy or disease below the diaphragm, most likely
represent secondary cardiac lymphomatous involvement. In
some studies, secondary heart involvement by lymphoma was
identified at postmortem in 10% to 30% of the cases. Lymphomas
represented more than 9% of the total metastases to the heart,
and up to 20% of patients with lymphoma are found, at autopsy,
to have cardiac involvement .
There are three main entities of mediastinal lymphomas: T
lymphoblastic lymphoma, mediastinal (thymic) diffuse large B
cell lymphoma, and classical Hodgkin lymphoma .
Cardiac involvement of a malignant lymphoma is usually a
late manifestation of the disease; it is difficult to make a definite
diagnosis in some cases. Therefore, treatment may be started
before histological confirmation. In our case, the definitive
diagnosis of lymphoma wasn’t possible after many transparietal
pleural biopsies and the biopsy of the supraclavicular
lymphadenopathy, so after a multidisciplinary discussion, it was
decided to start a trial corticosteroid therapy
Ischiwata et al.  described a rare case of malignant
lymphoma with diffuse cardiac and pericardium involvement
that initially presented as congestive cardiac failure. A tissue
diagnosis of the mediastinal mass could not be performed due
to the patient’s generally poor condition. The patient received
corticosteroid therapy, but died 42 days after her admission.
Mechanical cardiac tamponade is both a medical and surgical
emergency that can complicate mediastinal tumors, and may
in some cases of hemodynamically unstable patients, delay
the management of the underlying etiology. For histologically
unconfirmed compressive mediastinal lymphomas, trial
corticosteroid therapy may be considered.