Pericardial effusion of abnormal appearance in the setting of recent oesophageal surgery

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A patient in their 40s with gastric adenocarcinoma and recent oesophageal stent insertion presented to the emergency department with haemodynamic compromise. The oesophageal stent was inserted 3 weeks prior due to dysphagia from local disease recurrence. On admission, the patient had a blood pressure of 80/60 mm Hg, a heart rate of 120 bpm and was afebrile. He had a white cell count of 20.9×10 /L with a predominant neutrophilia of 12.02×10 /L and a C reactive protein of 409.2 mg/L. A transthoracic echocardiogram was urgently organised. It revealed a moderatesized, complexappearing global pericardial effusion with early signs of tamponade as evidenced by right ventricular and right atrial collapse, a dilated inferior vena cava with reduced inspiratory collapse and borderline significant inspiratory reduction of diastolic mitral inflow velocity. A pericardiocentesis was performed and 300 mL of a milky fluid was aspirated (figure 1). The main differentials of a milky pericardial aspirate are a purulent effusion, chylopericardium and cholesterol pericarditis, which are all rare disorders. Purulent pericarditis is a serious complication of bacterial pericarditis and is characterised by gross pus in the pericardium or microscopically purulent effusion. It is caused by bacterial invasion of the pericardium or by haematogenous spread . This condition is associated with a high mortality rate as it simultaneously threatens septicaemia and tamponade. Chylopericardium is a pericardial effusion composed of chyle and is associated with damage to the thoracic duct. It is diagnosed on pericardial fluid analysis with a triglyceride level greater than 500 mg/dL and a cholesterol/triglyceride ratio less than one. Cholesterol pericarditis is seen in the setting of chronic pericardial effusions, secondary to tuberculosis or rheumatoid pericarditis. It has an elevated cholesterol and total lipid levels like a chylopericardium but contains cholesterol crystals and differs in appearance. The fluid may vary in colour from being cloudy to amber and classically has a glittering ‘gold paint’ appearance. In this patient’s case, the recent oesophageal surgery raises another possibility of a communication between the Figure 1 Collection bag of pericardial fluid aspirate.