A 19-year-old female initially presented to an outside hospital with worsening shortness of breath over the course of hours. Echocardiogram revealed a large pericardial effusion with tamponade physiology. An urgent pericardiocentesis followed by a pericardial window yielded 600cc of cloudy fluid, and work-up for infectious, auto-immune, and malignant etiologies was unrevealing. She was discharged home, but over the next four weeks developed a repeat pericardial effusion requiring another pericardiocentesis yielding 750cc of cloudy fluid.
She then presented to our hospital two weeks later with progressive shortness of breath. Echocardiogram revealed a large pericardial effusion with evidence of early tamponade physiology. Our differential diagnosis for her recurrent pericardial effusions remained broad, with infectious and malignant etiologies at the top of consideration. Computed tomography of the chest demonstrated the pericardial effusion and mild mediastinal adenopathy. She underwent another pericardial window with removal of 600cc of milky fluid, and fluid analysis was notable for a markedly elevated triglyceride level consistent with a diagnosis of chylopericardium. Work-up for malignancy as an etiology for recurrent chylopericardium was negative. A percutaneous lymphangiogram was then performed, which revealed a significant leak in the superior aspect of the thoracic duct into the pericardial space. Percutaneous embolization of the thoracic duct was performed using detachable coils along with embolic glue, resulting in resolution of the leak. She has since remained asymptomatic, and follow-up echocardiogram was without recurrence of any pericardial effusion.
This case of idiopathic recurrent chylopericardium as the cause for pericardial effusion represents a rare manifestation of a relatively common cardiac condition. It illustrates the importance of routine pericardial fluid analysis for triglycerides, as this led to her correct diagnosis of chylopericardium. The use of percutaneous thoracic duct embolization has only recently been reported as a novel approach for treatment of chylous leak, and may emerge as a useful alternative to surgery for recurrent chylopericardium.
Emergency Department Echocardiography Demonstrates Large Pericardial Effusion and Pendulous Cardiac Motion in Patient with Shortness of Breath and Electrical Alternans
