A Prickly Pericardium

Abstract

INTRODUCTION: There are many causes of pericardial effusions, however it is unusual for a pericardial effusion to reaccumulate rapidly enough to cause recurrent tamponade physiology over a short time period. Here we present a case of recurrent pericardial tamponade from an extremely unusual cause. CASE PRESENTATION: A 49 y/o woman with a history of hypertension presented with chest pain for one week duration. Upon initial evaluation the patient was found to be tachycardic and her physical exam was significant for distant heart sounds. Initial laboratory data was only significant for a mildly elevated D-Dimer. In the Emergency Department, a CT scan of her chest showed a small pericardial effusion and a 4mm by 4mm aortic ulceration on the posterior wall of the ascending aorta that was initially suspected to be an aortic plaque. The effusion enlarged on a repeat CT chest on hospital day (HD) #2. The patient subsequently developed tamponade requiring a pericardial window. The fluid was noted to be serosanginous and further studies were negative for infection and malignancy. On HD #5 the pericardial effusion recurred with tamponade physiology requiring a second pericardial window with removal of 200 cc of bloody pericardial fluid. On HD #8 she required a third pericardial window secondary to recurrent tamponade with removal of 500 cc of blood and clots. On HD #15, CT angiography demonstrated that the aortic ulceration had enlarged, increasing in size to 6 mm by 6 mm and was also highly concerning for hemorrhage into the pericardial sac (Figure 1). On HD #17 the patient was taken for replacement of the ascending aorta due to the possibility of continued ulceration and erosion of the aortic wall. Intra-operatively the patient was found to have a foreign body penetrating into the posterior aortic wall, later identified by pathology to be a porcupine quill (Figure 2). DISCUSSION: Subsequent discussion revealed that the patient had spent significant time several weeks earlier removing porcupine quills from the face and the nose of the family dog. The patient reports that she was drinking a glass of ice tea throughout the time she spent removing the quills. It is suspected that the patient swallowed a porcupine quill and it subsequently eroded from the esophagus into the posterior wall of the ascending aorta. This was the cause of her recurrent hemorrhagic pericardial effusions as well. There was no further accumulation of the pericardial effusion or recurrence of tamponade since removal of the porcupine quill. The patient was discharged on HD #22 and has since done well. CONCLUSIONS: This case illustrates an extremely rare cause of pericardial effusion and tamponade physiology. Although this particular etiology is unlikely to be noted again, it highlights the importance of an aggressive diagnostic approach in cases of unexplained life-threatening illnesses.