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BATTLING PERICARDIAL EFFUSION

A pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity.

A 32 years old male consulted me on 13/10/12, who as per the reports was diagnosed at PGI & Super-specialty Hospital Nagpur, as Case of Pulmonary Tuberculosis - Left Pleural Effusion with Pericardial Effusion. He came with complaints of -
1. Fever, moderate grade, with chills, night sweats +, thirst scanty,
2. Chest pains- stabbing, involving the left precordium, radiating to the front of chest,
< Each breath, coughing and fatigue.
3. Dyspnoea (N.Y.H.A Gr III) < exertion, ascending stairs, and palpitations.
4. Cough with mucus expectoration. < Lying down, night. No haemoptysis.
All these complaints were present since 2 months and gradually increasing intensity. For these,he was investigated at Govt.Medical College Nagpur and was started on Anti-Koch’s regimen (2SHRZ + 6HR). 2 weeks after, he started getting eruptions on Skin - erythematous, macular, itchy rashes on both the lower extremities and trunk. The patient was given Steroids and anti-Histaminics by a private practitioner but with no relief. So he stopped the treatment on his own. Rashes subsided. After only 10 days he was once again admitted to PGI and Super-specialty Hospital for his respiratory symptoms & diagnosed as a case of Tuberculous Pericardial Effusion and restarted on Anti-Kochs regimen. It was during this time he approached us.
O/E -- Conscious, emaciated & febrile,
Pulse - regular 110/min, low volume, Rate - 24 /min,
BP -100/60 mm Hg,
Pallor++ No Icterus / Cyanosis/ Clubbing
No Signs of Congestive Cardiac Failure
Per Abdomen - Liver/ Spleen – Not Palpable.
No evidence of Ascites.
Sounds present in all 4 quadrants.
Cardiovascular System - Apex not palpable,
Heart Sounds 1st & 2nd - muffled,
No pericardial rub.
Respiratory System - Trachea to the Right.
Air entry - absent in the infra axillary region. Crepitations in the left infra- scapular region.
Central Nervous System - N.A.D.

Usually pericardial effusion(PE) is not found behind the left atrium,because the pericardial attachments are refleted onto the pulmonary veins.Somtimes,PE can be visualized in the oblique sinus,which is located behind the LA. A PE is anterior to the descending aorta,whereas a pleural effusion(PL) is posterior to the aorta.



Investigations -- Blood - Hb- 8.2gm%,
TLC- 11,800/cu mm, Lymphocytosis.
ESR- 46 mm in the 1st hour.
Blood Urea - 28mg %,
S. Creatinine- 1.4 mg %,
Liver Function Test - Normal,
Rheumatiod Arthritis Factor - Negative
X-Ray Chest PA – Left Pleural Effusion with mid zone consolidation, Cardiomegaly ++
USG abdomen – Within Normal Limits,
ECG - Global T wave inversion with low voltage complexes with sinus tachycardia.
2D ECHO- Mild Pericardial effusion, Dilated Left Ventricle with good Systolic function, Left Ventricular Ejection Fraction - 72%, No Regional Wall Motion Abnormality, Valves normal, Aorta Normal, No intracardiac clot / mass.

Rx Pulsatilla 0/1 3 doses x 1 day. Omit AntiTB drugs

14/10: Febrile, emaciated, Pulse - 100/m, regular. R-22/min,
BP - 100/64 mm Hg, pallor ++
RS - Trachea shifted to Right, Left Infrascapular crepts +, Left. Pleural effusion +
CVS - apex not palpable, Heart Sounds soft, No rub, No gallop. S/O Pericardial effusion +
CNS – NAD, Abdomen - NAD
Rx - Pulsatilla 0/2 3 doses x 1 day

15/10: Dyspnoea +, Fever less, cough, expectoration ++,
Rx - Pulsatilla 0/3 x 3 doses, SL x 3 days.

18/10: No Fever. Dyspnoea +++, Cough ++
P-100/min, BP -110/70, RS - Left Infra-scapular crepts less. Left pleural effusion +
Rx- Kali iod 30 fractional doses x 3days, Omit Puls.

24/10: Patient felt better. Dyspnoea reduced.
Cough with expectoration +, vitals stable, crepts reduced . Pl.effusion +
Rx- SL x 10 days

3/11: Patient better. Dyspnoea / chest pain > Cough with expectoration persistent.No Crepts, Pleural effusion +
Rx- Kali iod 200 3 doses x 1 day, SL x 10 days

Patient’s sister stated - Sir, we are a poor family of 7 members consisting of my parents, one elder brother with his wife, and my second brother with his wife and me. My father is suffering from paralysis (right) since 12 years. My brother (patient) has worked hard throughout his life as a mechanic, since 17-18 years of age. He has spent every paise of his earnings on our father’s medication as well as our studies. Since my younger brother married last year our family is disturbed. Practically every other day there are some quarrels. My 2nd brother has completely changed after his marriage, which ultimately ended in his separation. Since then, my brother (patient) has become sad and despondent. He has even stopped going to work and now this disease. He has slight burning and increased frequency of urination. His thirst is less and gets 2-3 loose motions especially before going to bed and after tea.
During the conversation, the patient lamented on his frustrations. For him life had become a burden. He said, “I wish I would die, rather than making others suffer due to my sickness.” I inquired, how did he take his brothers attitude? He said, although as a brother I think he is right, but whenever I think of the incident, I feel hurt.
He said “I am better when I sleep in our verandah, which has a cool breeze. As such my sleep is sound, but at times, I get fearful dreams of people stealing from my house.” His sister added that he was basically mentally strong and full of hope. He was sensitive and got angry whenever anyone failed to perform his or her duties. She said “ Even with our poor conditions our brother did too much, but still feels guilty of not doing enough.”

Past History - Recurrent attacks of Bronchitis < winter, Chronic Suppurative Otitis Media - Left ear (7 to 13 of years age)

Family History - Father – Hypertensive with Right sided hemi paresis, Mother - Ulcerative colitis,
Maternal Uncle died of Pulmonary Kochs

14-11: Rx Aurum met 1M 1dose stat with SL 1 TDS x 1mth

18-11: Complaints much better, Depression >>, Chest pain > dyspnoea >Vitals stable. Chest clear. HS pure,
ECG/ ECHO - No fresh changes. Rx Ct SL 1 TDS for 2 months

12-1-13 No major problems, Afebrile, No cough or Dyspnoea ,
Chest clear, HS pure. P 84/min reg, BP- 110/70 mm Hg, ECG – WNL
Rx Tuberculinum bov 1M 1 dose

5-3-13 No complaints-, Chest pain much reduced, No cough or fever,
Stools constipated, Urine 4-6/d occasionally at night
Haemoglobin - 9.9gm %,
Total Leuco Count - 9,700/cu mm, Diff Leuco Count – P 56%,L 40%,E 3% & M 1%
Erythrocyte Sedimentation Rate - 30 mm in 1st hr
XRay Chest PA - No Pleural Effusion, ECG - WNL.
2D ECHO- No Pericardial effusion,systolic function good,
LVEF - 78%,, Valves normal, Aorta N, No intracardiac clot or mass. No RWMA.
Rx continue SL 1 TDS for 2 months

Discussion
This is Case Type II – There are gross pathological changes with secondary symptoms. Miasmatic evolution is as follows- Psoric state of disposition got evolved due to suppressions of ear discharges into a Psorsyphillitic state. It expressed at both the planes on the mental plane in the form of Depressions, sadness and despondency. Fearful dreams and feeling of guilt are also other expressions of the Tubercular state. Collection of fluid in the pleural and pericardial cavities are Tubercular eliminates.
1. Pulsatilla was given as a short acting remedy for evening rise of fever with chills, less thirst, desire for open air. Cough with mucus expectoration. < Lying down, night. Kent says Pulsatilla is very useful in Catarrahal Phthisis (Page 757 Kent MM)
2. Kali Iod given on the basis of the pathological totality of Lt Pleural effusion, intense cough and dyspnoea with palpitations < warm room exertion & > open air. Chill with Fever < night. Follows well after Pulsatilla. [Herings Guiding Symptoms- Page 433 (VI). It did relieve the distressing symptoms of cough and breathlessness.
3. Aurum met a Chilly drug with general < after cold & winters. Basically the Patient was a strong personality with lot of hard work. He is rigid on himself but soft to others. Feeling of self - condemnation, worthlessness, loathing of life, and dreams of robbers. Kent says that in these patients, the fundamental love of life is perverted with horrible depression of spirit, self-condemnation, continual self-reproach and self-criticism and constant looking into self and feels that he has neglected his duties (Page 165 Kent Materia Medica). There is a strong desire for open air. Heart affections as dyspnoea, palpitation, chest pain < ascending stairs, exertion >open air, along with hopelessness and despair & Past History - obstinate otorrhoea. This drug acted as Similimum – most appropriately selected homoeopathic remedy.
4. Tuberculinum bovinum has been given as an intercurrent to prevent relapses and was selected on the basis of Pathological changes. The patient had loose motions during Tubercular infection. Past History of recurrent attacks of Bronchitis < winter, and F/H - Tb, Ulcerative colitis & Hemiplegia (all Tubercular disorders)

Pericardial effusion is the accumulation of excess fluid around the heart often related to inflammation of the pericardium that's caused by disease or injury. Dawn E. Jaroszewski, M.D., a cardiothoracic surgeon, at Mayo Clinic in Arizona, explains the process of a minimally invasive procedure to treat pericardial effusion.

Please note: This video contains graphic images of a surgical procedure.

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