Abstracts
PO52
Cardiac Tamponade as the Initial Presentation of Diffuse Large B-Cell Lymphoma
Introduction/Background/Significance: Diffuse large B-cell lymphoma (DLBCL) rarely involves the heart, and cardiac tamponade as the initial presentation is exceedingly uncommon. However, as associated symptoms such as shortness of breath and fatigue overlap with pneumonia, heart failure, and other cardiopulmonary conditions, diagnosis of DLBCL is often delayed.
Materials and Methods/Case Presentation/Objective: An 87-year-old male with a history of prostate cancer treated with radiation therapy, heart failure with preserved ejection fraction, and hypothyroidism presented with progressive dyspnea. He was initially treated outpatient for pneumonia; however, despite completing antibiotics, he had worsening symptoms. This prompted emergency department evaluation, where initial findings were notable for cardiomegaly on chest x-ray with pulmonary edema and bibasilar pleural effusions, and the patient was initially assumed to be experiencing a heart failure exacerbation. However, CT imaging revealed a moderate-to-large pericardial effusion, prompting further evaluation with a transthoracic echocardiogram, which demonstrated tamponade physiology. The patient required emergent pericardiocentesis with drainage of 450 mL of fluid. Once stable, the patient had thoracentesis two days later, yielding 1,100 mL of fluid. Cytologic examination of both fluids demonstrated DLBCL, activated B-cell type. Immunophenotyping showed positivity for CD20, BCL2, and MUM1, with a Ki-67 proliferative index of approximately 95%, and negative staining for CD10, BCL6, EBV, and HHV-8. Notably, the patient was otherwise asymptomatic prior to presentation, only complaining of progressive fatigue and reduced appetite over the preceding months, making this an atypical presentation of DLBCL.
Results/Description/Main Outcome Measure(s):
Conclusion(s).: This case illustrates that DLBCL can present as cardiac tamponade without a prior lymphoma diagnosis, mimicking more common cardiopulmonary etiologies such as heart failure or infectious pneumonia. Secondary cardiac involvement occurs in a small proportion of disseminated DLBCL cases, and presentation with pericardial effusion or tamponade as the initial finding is distinctly rare, which may contribute to diagnostic delay when clinicians anchor on more common causes of dyspnea and effusion. Cytologic analysis of pericardial and pleural fluid, supported by immunophenotyping, helps in obtaining a diagnosis without the need for tissue biopsy, allowing a faster path to treatment than would be expected with surgical sampling. This approach is particularly valuable in patients who are poor candidates for invasive biopsy due to comorbidities. Historically, cardiac involvement by aggressive lymphoma has portended a poor prognosis, but prompt effusion drainage combined with early immunochemotherapy may mitigate this risk. DLBCL should remain in the differential diagnosis of unexplained or recurrent pericardial and pleural effusions, particularly when tamponade develops without an obvious infectious, autoimmune, or structural cause. Rapid cytologic evaluation of serous fluid can shorten time to diagnosis and facilitate timely, potentially lifesaving treatment.
Trademarked Items:
References:
Materials and Methods/Case Presentation/Objective: An 87-year-old male with a history of prostate cancer treated with radiation therapy, heart failure with preserved ejection fraction, and hypothyroidism presented with progressive dyspnea. He was initially treated outpatient for pneumonia; however, despite completing antibiotics, he had worsening symptoms. This prompted emergency department evaluation, where initial findings were notable for cardiomegaly on chest x-ray with pulmonary edema and bibasilar pleural effusions, and the patient was initially assumed to be experiencing a heart failure exacerbation. However, CT imaging revealed a moderate-to-large pericardial effusion, prompting further evaluation with a transthoracic echocardiogram, which demonstrated tamponade physiology. The patient required emergent pericardiocentesis with drainage of 450 mL of fluid. Once stable, the patient had thoracentesis two days later, yielding 1,100 mL of fluid. Cytologic examination of both fluids demonstrated DLBCL, activated B-cell type. Immunophenotyping showed positivity for CD20, BCL2, and MUM1, with a Ki-67 proliferative index of approximately 95%, and negative staining for CD10, BCL6, EBV, and HHV-8. Notably, the patient was otherwise asymptomatic prior to presentation, only complaining of progressive fatigue and reduced appetite over the preceding months, making this an atypical presentation of DLBCL.
Results/Description/Main Outcome Measure(s):
Conclusion(s).: This case illustrates that DLBCL can present as cardiac tamponade without a prior lymphoma diagnosis, mimicking more common cardiopulmonary etiologies such as heart failure or infectious pneumonia. Secondary cardiac involvement occurs in a small proportion of disseminated DLBCL cases, and presentation with pericardial effusion or tamponade as the initial finding is distinctly rare, which may contribute to diagnostic delay when clinicians anchor on more common causes of dyspnea and effusion. Cytologic analysis of pericardial and pleural fluid, supported by immunophenotyping, helps in obtaining a diagnosis without the need for tissue biopsy, allowing a faster path to treatment than would be expected with surgical sampling. This approach is particularly valuable in patients who are poor candidates for invasive biopsy due to comorbidities. Historically, cardiac involvement by aggressive lymphoma has portended a poor prognosis, but prompt effusion drainage combined with early immunochemotherapy may mitigate this risk. DLBCL should remain in the differential diagnosis of unexplained or recurrent pericardial and pleural effusions, particularly when tamponade develops without an obvious infectious, autoimmune, or structural cause. Rapid cytologic evaluation of serous fluid can shorten time to diagnosis and facilitate timely, potentially lifesaving treatment.
Trademarked Items:
References:
