No abstract

Background. Chylopericardium is the accumulation of lymphatic fluid in the pericardial cavity. It can be idiopathic or secondary to trauma, cardiothoracic surgery, neoplasm, radiation, tuberculosis, lymphatic duct dysfunction, thrombosis, or other causes. We present a case of chylopericardium due to subclavian vein thrombosis in a patient with protein S deficiency. Clinical Case. A 48-year-old man with a history of protein S deficiency presented to the emergency department with shortness of breath and a productive cough. CT of the chest showed pulmonary emboli, moderate pericardial effusion, and a large thrombus of the superior vena cava, brachiocephalic vein, and subclavian veins. He developed echocardiographic evidence of cardiac tamponade so he underwent pericardiocentesis with drainage of milky-appearing fluid. Analysis of the fluid showed elevated triglycerides consistent with chylopericardium. The pericardial effusion reaccumulated, likely secondary to lymphatic duct obstruction due to his subclavian vein thrombus. Catheter-assisted thrombolysis was performed with resolution of the patient’s effusion and symptoms. Conclusion. Chylopericardium is a rare but important complication of subclavian vein thrombosis. Management is typically with surgical intervention, although our case represents successful treatment with catheter-assisted thrombolysis.

Background. Right heart thrombus or clot in transit is a rare venous thromboembolism (VTE) with high mortality. COVID-19 infection has been associated with increased risk of such events. We present the case of a 63-year-old man with no traditional VTE risk factors who was diagnosed with a clot in transit three weeks after diagnosis of COVID-19. Clinical Case. A 63-year-old male with no significant past medical history who presented to the emergency department with shortness of breath. He tested positive for COVID-19 three weeks prior. His oxygen saturation was 60% on room air and was put on nonrebreather mask. He was still showing signs of respiratory distress including tachypnea, tachycardia, diaphoresis, and accessory muscle use. The patient was subsequently intubated and mechanically ventilated. Chest computed tomography with contrast showed acute bilateral pulmonary emboli with flattening of the interventricular septum suggestive of right heart strain. Bedside echocardiogram showed severely enlarged right ventricle with reduced systolic function and evidence of right ventricular strain and a mobile echodensity in the right ventricle attached to the tricuspid valve consistent with a clot in transit. The patient was treated with full dose systemic thrombolysis with rapid improvement in his symptoms. He was extubated the following day and a repeat echocardiogram showed resolution of the clot in transit. Conclusion. Clot in transit is rare but can occur in COVID-19 patients even in the absence of traditional thromboembolism risk factors. Management includes systemic anticoagulation, systemic thrombolysis, and surgical embolectomy. Our patient was successfully treated with systemic thrombolysis.

Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that involves persistent respiratory symptoms and airflow limitation. Several studies have shown increased prevalence of psychiatric illness (PI) in patients with COPD; however, prevalence rates vary widely. Hypoxemia in COPD has been associated with increased risk of cognitive and neuropsychiatric impairment while depression was associated with lower treatment adherence in patients with COPD. Despite these associations, studies investigating the effects of PI on COPD mortality and readmission remain inconclusive. This study aims to describe the prevalence of PI in COPD and evaluate the effect of PI on in-hospital mortality and 30-day readmissions using large United States population-based dataset.METHODS: Data were abstracted from the 2010 to 2018 Nationwide Readmissions Database (NRD). Hospitalizations with a primary diagnosis of COPD were identified using Diagnosis Related Groups 190 to 192 and/or All Patients Refined-Diagnosis Related Groups 140; International Classification of Diseases-9/10-Clinical Modification codes were used to identify secondary PI diagnoses of major depression, bipolar disorder, post-traumatic stress disorder, anxiety disorder, somatoform disorder, sleeprelated disorders, eating disorders, and/or alcohol use disorder. Multivariable logistic regression models were estimated to evaluate the effect of PI on mortality and 30-day readmissions. All analyses accounted for the NRD sampling design.RESULTS: A total of 6,452,636 hospitalizations with COPD occurred between 2010 and 2018. Of these, 2,160,417 (34%) carried at least one PI diagnosis. The most prevalent PI was anxiety disorder (58%) followed by sleep-related disorders (26%), and major depression (20%); Concomitant PI was more prevalent in hospitalizations in which patients were younger, female, nicotine users, and obese (P-value <0.001).Hospitalizations with concomitant PI had higher adjusted mortality rate [adjusted odds ratio (aOR): 1.07; 95% confidence interval (CI): 1.04-1.10, P-value <0.001], as well as higher 30-day readmission rates [aOR: 1.21, 95% CI: 1.20-1.22, P-value <0.001]. CONCLUSIONS:This study demonstrates that in the United States from 2010 to 2018, approximately one-third of COPD hospitalizations have a concomitant PI that is associated with higher mortality and 30-day readmission rates.CLINICAL IMPLICATIONS: COPD patients with PI should be recognized as a vulnerable population at increased risk for inhospital mortality and 30-day readmission. Further studies are needed to develop tools and measures that help identify and screen this group of patients.