{"id":2627,"date":"2026-05-03T01:18:07","date_gmt":"2026-05-03T01:18:07","guid":{"rendered":"https:\/\/emultrasound.ucsd.edu\/?p=2627"},"modified":"2026-05-03T01:18:10","modified_gmt":"2026-05-03T01:18:10","slug":"case-70-a-silent-and-rapid-expansion","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/2026\/05\/03\/case-70-a-silent-and-rapid-expansion\/","title":{"rendered":"Case 70: A Silent and Rapid Expansion"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Natalie Sarafian, Elaine Yu<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 62-year-old male with a history notable for HFrEF (on Lasix), HIV, cirrhosis with varices, ulcerative colitis, methamphetamine use, and Hodgkin\u2019s lymphoma (in remission) presents to the emergency department with acute onset shortness of breath and chest pain. His exertional dyspnea and exertional chest pain are also accompanied with lower extremity edema and orthopnea. Cardiac history is significant for CHF diagnosed in 2020, with a hospitalization in September 2025 for ADHF, and multiple recurrent admissions after being unable to take GDMT medications. Currently, he is adherent but misses medications about once weekly.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Vitals: <\/strong>BP 114\/85, HR 103, RR 23, SpO2 94%, BMI 28.98<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Physical exam:<\/strong> 2+ pitting edema in lower extremities bilaterally with a venous stasis rash<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Labs:<\/strong> Troponin 85. BNPP &gt; 13,000. Cr 1.23. Bilirubin of 1.54.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>EKG<\/strong>: normal sinus rhythm with LBBB<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A bedside ultrasound was performed:<\/p>\n\n\n\n<figure class=\"wp-block-video\"><video height=\"1116\" style=\"aspect-ratio: 1700 \/ 1116;\" width=\"1700\" controls src=\"https:\/\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/POCUS-PSL-1.mov\"><\/video><figcaption class=\"wp-element-caption\">Figure 1: Parasternal long axis view with severely decreased ejection fraction with trace pericardial effusion.<\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-video\"><video height=\"1116\" style=\"aspect-ratio: 1700 \/ 1116;\" width=\"1700\" controls src=\"https:\/\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/POCUS-PSS-1.mov\"><\/video><figcaption class=\"wp-element-caption\">Figure 2: Parsternal short axis view with global hypokinesia and trace pericardial effusion.<\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>ED Course: <\/strong>Cardiology was paged for the LBBB with troponin leak and heart failure exacerbation, with plan to admit to their service. In the interim, students performed another bedside ultrasound a few hours later for education.<\/p>\n\n\n\n<figure class=\"wp-block-video\"><video height=\"1116\" style=\"aspect-ratio: 1700 \/ 1116;\" width=\"1700\" controls src=\"https:\/\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/POCUS-PSL-2.mov\"><\/video><figcaption class=\"wp-element-caption\">Figure 3: Repeat examination showing increasing size of pericardial effusion.<\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Discussion:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pericardial effusion management is routinely taught in medical education and encountered clinically. Pericardial effusions are present in about 6.5% of the general adult population and in 13-20% of high-risk emergency department patients [1]. Given its potential of developing into tamponade and its association with multiple diseases, prompt diagnosis is of utmost importance for proper treatment and prognosis of patients. Cardiac tamponade is an emergent consequence of a rapidly growing pericardial effusion, but it is infrequently encountered, with an incidence of 2 per 1000 people [2]. It is important to note that not all large pericardial effusions will devolve into tamponade; rather, a rapid rate of fluid accumulation creates tamponade [3].<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The likelihood of discovering a pericardial effusion changes with a patient\u2019s risk factors and underlying pathology. This patient had multiple comorbidities that are associated with cardiac pathology, including but not limited to CHF, methamphetamine use, HIV, lymphoma, and ulcerative colitis. In a meta-analysis of patients with pulmonary arterial hypertension, myocardial infarction, malignancy, and chronic heart failure, the pooled pericardial effusion prevalence was 19.5% [1]. Although pleural effusions are more common than pericardial effusions in CHF [5], pericardial effusions still demonstrate increased risk for all-cause mortality in CHF patients [6]. Now with antiretroviral therapies, studies have demonstrated low rates of pericardial effusions in HIV-positive outpatients [4]. Finally, the pericardium is a common site for lymphomas to metastasize [7], thus malignant pericardial effusions should also be considered in cancer patients.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Although echocardiograms are the basis of diagnosing pericardial effusions, a patient\u2019s history, examination, EKG, or chest x-ray may raise suspicion [3]. Additionally, bedside ultrasound can also serve as an efficient and noninvasive diagnostic tool. POCUS has been found to reduce time to pericardiocentesis and expedite echocardiograms if indicated [8]. In fact, POCUS can be performed to confirm a pericardial effusion with 96-100% sensitivity and specificity [9]. Furthermore, when pericardial effusions are diagnosed in the emergency department, patients experience shorter hospital stays and reduced mortality [10].<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"190\" src=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/image.png?resize=525%2C190&#038;ssl=1\" alt=\"\" class=\"wp-image-2631\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/image.png?resize=1024%2C371&amp;ssl=1 1024w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/image.png?resize=300%2C109&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/image.png?resize=768%2C278&amp;ssl=1 768w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/image.png?w=1110&amp;ssl=1 1110w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><figcaption class=\"wp-element-caption\">Source: <a href=\"https:\/\/www.pocus.org\/pocusevaluation-of-pericardial-effusion-and-tamponade\/\" type=\"link\" id=\"https:\/\/www.pocus.org\/pocusevaluation-of-pericardial-effusion-and-tamponade\/\">POCUS.org<\/a><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">When using POCUS to evaluate for pericardial effusions, measuring the effusion can help approximate the volume. It is important to note that up to 50 mL of fluid is normal and physiologic [10]. If there is clinical concern for tamponade, POCUS should evaluate for right ventricular diastolic collapse, late right atrial diastolic collapse, heart swinging, plethoric IVC, and mitral and tricuspid valve respirophasic flow variation [10]. Once a pericardial effusion and\/or cardiac tamponade has been identified and diagnosed, treatment, ranging from conservative management to pericardiocentesis, should be considered.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In this patient\u2019s case, the pericardial effusion was deemed small-moderate by the cardiology service and will be followed up with a formal echocardiogram.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>References:<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Argulian, E. &amp; Vogel, B. (2024) Evaluation of pericardial effusion. BMJ Publishing Group.<\/li>\n\n\n\n<li>Brown, B., Nigussie, B., Offor, R., &amp; Graham-Hill, S. (2024). Fatal cardiac tamponade: The lethal progression of acute-on-chronic pericardial effusion. Cureus, PMC11264569.<\/li>\n\n\n\n<li>Shanker, D. A., Gaur, A., &amp; Warriner, D. (2025). Pericardial effusion: Overview of aetiology, pathophysiology, diagnosis, and management. Cureus. https:\/\/pubmed.ncbi.nlm.nih.gov\/41084698\/<\/li>\n\n\n\n<li>Lind, A., Reinsch, N., Neuhaus, K., Esser, S., Brockmeyer, N. H., Potthoff, A., Pankuweit, S., Erbel, R., Maisch, B., &amp; Neumann, T. (2011). Pericardial effusion of HIV-infected patients: Results of a prospective multicenter cohort study in the era of antiretroviral therapy. European Journal of Medical Research, 16(11), 480\u2013483. https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC3351804\/<\/li>\n\n\n\n<li>Natanzon, A. &amp; Kronzon, I. (2009). Pericardial and pleural effusions in congestive heart failure\u2014Anatomical, pathophysiologic, and clinical considerations. The American Journal of the Medical Sciences, 338(1). https:\/\/pubmed.ncbi.nlm.nih.gov\/19574887\/<\/li>\n\n\n\n<li>Georg M. Fr\u00f6hlich, Philipp Keller, Florian Schmid, Mathias Wolfrum, Martin Osranek, Christian Falk, Georg Noll, Frank Enseleit, Markus Reinthaler, Pascal Meier, Thomas F. L\u00fcscher, Frank Ruschitzka, Felix C. Tanner, Haemodynamically irrelevant pericardial effusion is associated with increased mortality in patients with chronic heart failure, European Heart Journal, Volume 34, Issue 19, 14 May 2013, Pages 1414\u20131423, https:\/\/doi.org\/10.1093\/eurheartj\/eht006<\/li>\n\n\n\n<li>Mudra, S. E., Rayes, D., Kumar, A. K., Li, J. Z., Njus, M., McGowan, K., Charalampous, C., Kalam, K. A., Syed, A., Majid, M., Schleicher, M., Agrawal, A., Yesilyaprak, A., &amp; Klein, A. L. (2024). Malignant pericardial effusion: A systematic review. CJC Open, 6(8), 967\u2013972. https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC11357784\/<\/li>\n\n\n\n<li>Moura de Azevedo, S., Duarte, R., Krowicki, J., V\u00e1zquez, D., Pires Ferreira Arroja, S., &amp; Mariz, J. (2024). Heart in focus: Advancing pericardial effusion diagnosis with point-of-care ultrasound. Cureus, 16(12), e76681. https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC11781757\/<\/li>\n\n\n\n<li>Merth, T. &amp; Sachdeva, S. (2022). Pericardial effusion and tamponade: Diagnosis and treatment summary. https:\/\/emergencycarebc.ca\/clinical_resource\/clinical-summary\/pericardial-effusion-and-tamponade-diagnosisand-treatment-summary\/<\/li>\n\n\n\n<li>Rao, V. (2025). POCUS evaluation of pericardial effusion and tamponade. https:\/\/www.pocus.org\/pocusevaluation-of-pericardial-effusion-and-tamponade\/<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"Natalie Sarafian, Elaine Yu A 62-year-old male with a history notable for HFrEF (on Lasix), HIV, cirrhosis with varices, ulcerative colitis, methamphetamine use, and Hodgkin\u2019s lymphoma (in remission) presents to the emergency department with acute onset shortness of breath and chest pain. His exertional dyspnea and exertional chest pain are also accompanied with lower extremity &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/2026\/05\/03\/case-70-a-silent-and-rapid-expansion\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Case 70: A Silent and Rapid Expansion\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[4],"tags":[7,161],"class_list":["post-2627","post","type-post","status-publish","format-standard","hentry","category-clinical-cases","tag-echocardiography","tag-pericardial-effusion"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Case 70: A Silent and Rapid Expansion - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/2026\/05\/03\/case-70-a-silent-and-rapid-expansion\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Case 70: A Silent and Rapid Expansion - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Natalie Sarafian, Elaine Yu A 62-year-old male with a history notable for HFrEF (on Lasix), HIV, cirrhosis with varices, ulcerative colitis, methamphetamine use, and Hodgkin\u2019s lymphoma (in remission) presents to the emergency department with acute onset shortness of breath and chest pain. 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