Malignant Pleural Mesothelioma presenting with Cardiac Tamponade- A Rare Case report and Review of the literature

Abstract

Mesothelioma is a rare tumor of the pleura, peritoneum, pericardium or tunica vaginalis. About 2,500 cases are diagnosed annually in the United States. Mesothelioma often presents with pleuritic chest pain and dyspnea related to local invasion; distal metastasis and lymphadenopathy at the time of diagnosis is rare. Pericardial involvement in mesothelioma is related to direct invasion of the tumor. We here present a 71 year-old-male who presented with pleuritic chest pain and dyspnea, noted to have diffuse ST-segment elevation in EKG and cardiac tamponade physiology on 2D echocardiogram in who imaging subsequently revealed left upper lung mesothelioma. A pericardial window was created following which tamponade resolved. The pericardial biopsy did not show any mesothelioma cells or fibrous plaques. Computer tomography revealed regional lymphadenopathy in the chest. Disrupted cardiac lymphatic flow due to tumor mesothelioma induced lymphadenopathy is likely cause of the cardiac tamponade in this patient. This is the second ever reported case of pleural mesothelioma without a direct pericardial invasion that presented with cardiac tamponade.

Mesothelial Cells in Lymph Nodes Associated with Massive Pericardial and Bilateral Pleural Effusion, a Diagnostic Dilemma: Report of a Case

“…However, based on recent reports, almost 15% of cases with malignant pleural mesothelioma were younger than the age 40 and it was equally found among men and women in the younger age group [2,4,9]. According to previous studies more than 80% of the patients are male and asbestos exposure history has been reported in more than 80% of patients [2,4,10]. In 1980 asbestos was widely abandoned as it was known as a strong risk factor for malignant mesothelioma [10].…”

“…According to previous studies more than 80% of the patients are male and asbestos exposure history has been reported in more than 80% of patients [2,4,10]. In 1980 asbestos was widely abandoned as it was known as a strong risk factor for malignant mesothelioma [10]. Chronic exposure to silica and other chemicals, dust, SV40 virus and cigarette smoking are some of other contributing factors considered in previous studies [1,4,10].…”

“…Although malignant pleural effusion as a result of plasma extravasation and obstruction of pleural lymphatic outflow is the first clinical presentation of 90% of mesotheliomas, pericardial involvement is rare [13]. Usually, in pericardial involvement, direct tumor invasion is associated [10]. The most typical presentation is a recurrent unilateral pleural effusion which is sometimes exudative and hemorrhagic [5,6].…”

“…Progression of malignant pleural mesothelioma is through local invasion into the mediastinum, parietal pleural fibrous tissue, extrapleural adipose tissue, and soft tissues of the chest wall and diaphragm [14]. Local invasion is a common occurrence and it can cause lymphadenopathy, SVC syndrome, vocal cord paralysis, Horner's syndrome, cardiac tamponade, and increased subcutaneous thickness [10,15]. Due to its hidden growth the tumor is found when it is relatively large or advanced in stage [15].…”

“…It is not typical for malignant mesothelioma to present with paraneoplastic thrombosis in lymph nodes [1,10]. The basic problem with the presence of mesothelial cells in lymph nodes, is the diverse list of differential diagnoses; namely, sinus histiocytosis, benign intranodal mesothelial cell inclusion, metastatic carcinoma, and metastatic mesothelioma.…”