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 »  Abstract
 » Introduction
 » Case Report
 » Discussion
 » Conclusion
 »  References
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 Table of Contents    
Year : 2012  |  Volume : 16  |  Issue : 4  |  Page : 219-221

Unusual presentation of pericardial effusion

Department of Critical care, Sevenhills Hospital, Marol Maroshi Road,Andheri (East), Mumbai, Maharashtra, India

Date of Web Publication25-Jan-2013

Correspondence Address:
Sanjith Saseedharan
4/205, Manish Darshan, J.B.Nagar, Andheri (East), Mumbai- 400059, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-5229.106507

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 » Abstract 

Cough syncope is classically described in patients with chronic obstructive pulmonary disease, and it is quite rare to find a treatable condition for the same. However, it is extremely rare to have cough syncope due to pericardial effusion. We present a case of pericardial effusion who presented to the intensive care with cough syncope.

Keywords: Cardiac tamponade, cough syncope, pericardial effusion

How to cite this article:
Saseedharan S, Kulkarni S, Pandit R, Karnad D. Unusual presentation of pericardial effusion. Indian J Crit Care Med 2012;16:219-21

How to cite this URL:
Saseedharan S, Kulkarni S, Pandit R, Karnad D. Unusual presentation of pericardial effusion. Indian J Crit Care Med [serial online] 2012 [cited 2015 Sep 3];16:219-21. Available from:

 » Introduction Top

The exaggerated valsalva induced by cough is classically described in patients suffering from chronic obstructive pulmonary disease. Constrictive pericarditis (called as the "heart of stone" in the bible) and pericardial effusion can present with cough. Tussive syncope has been well described in literature pertaining to constrictive pericarditis. However, it is extremely rare to have cough syncope in a case of pericardial effusion. We describe a case of tussive syncope in an elderly gentleman with pericardial effusion elucidating the basic pathophysiology of this interesting syncopal syndrome.

 » Case Report Top

64-years-old male, chronic alcoholic since last 30 years and ex-smoker (9 pack years), hypertensive on tab amlodipine 2.5 mg od, presented with a 15 days history of cough associated with mucopurulent expectoration and 3-4 episodes per day of unconsciousness associated with cough since the last 2 days The syncopal episodes lasted for 30 seconds to 1 minute with complete recovery after syncope. During one of the syncopal event, he had a fall, which was associated with scalp injury and epistaxis. No vomiting or seizure was reported during the syncopal event. On admission to hospital, he was normotensive, with a pulse rate of 80/min, with a blood pressure of 110/70 mm of hg. On physical examination, he was found to have palpable right supraclavicular lymph node, which was firm to hard, mobile, and non-tender, and JVP was not raised. Breath sounds were decreased in the lower right hemithorax. The hemoglobin level was 13.4 g/dL, leukocyte count of 11000/cmm. The chest x-ray showed right hilar prominence. A high-resolution contrast-enhanced CT scan of the chest was performed, which showed a concentric thickening of tracheobronchial tree, which was more pronounced in the lower lobe of the right lung with distal consolidation and ground-glass opacities. Moderate bilateral pleural effusions and a moderate pericardial effusion were also seen. Fine needle aspiration of right supraclavicular lymph node showed Metastatic Non-Small Cell Carcinoma.

Transthoracic echocardiography revealed moderate pericardial effusion with 2 cm of fluid behind the posterior wall of the left ventricle [Figure 1], no diastolic collapse of the ventricles. The IVC did not collapse with respiration. The heart valves and left ventricular systolic function were normal, with an ejection fraction of 60%.
Figure 1: Echocardiographic picture of pericardial effusion

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An episode of cough syncope was witnessed in the ICU, during which the systolic blood pressure showed a 60 mm drop, along with tachycardia. After recovery from this episode, an echocardiogram was repeated, which showed evidence of tamponade in the form of early diastolic collapse of right ventricle, late diastolic right atrial inversion with abnormal movement of the septum when the patient coughed, which disappeared when he stopped coughing.

Pericardiocentesis was performed, 500 ml of hemorrhagic fluid was drained, and a pigtail catheter was placed for further drainage of fluid. After drainage of the pericardial fluid, the patient did not experience any further episodes of cough syncope.

The pericardial fluid too showed numerous mesothelial cells and clusters of atypical cells, which were identified as metastatic Non-Small Cell Carcinoma.

 » Discussion Top

Cough syncope is well recognized but uncommon phenomenon where increased intra-thoracic pressure leads to decreased cardiac output, increased intracranial pressure, cardiac arrhythmias, stimulation of a hypersensitive carotid sinus, neural reflex-mediated hypotension-bradycardia, laryngospasm, and left ventricular outflow obstruction leading to decreased cerebral blood flow.

Cardiac tamponade due to pericardial effusion too may cause syncope by compromising cardiac output. These patients generally have tachycardia, distended neck veins, muffled heart sounds, and pulsus paradoxus. [1] The characteristic feature seen on echocardiography is the invagination of the right ventricular free wall in early diastole with further invagination of the right atrial wall at end diastole as pericardial pressure prevents adequate diastolic filling of the cardiac chambers. [2],[3] Our patient did not exhibit any of these signs, except during bouts of coughing.

It is likely that our patient was in a "pre-tamponade" state where the amount of pericardial fluid was just below the limit of pericardial reserve, beyond which cardiac output gets compromised. [4] The true filling pressure of the heart is the transmural pressure, which is the difference between the intracardiac pressure and the external pressure, which is the sum of the pericardial pressure and the intrathoracic pressure. In most patients with syncope, it is either the pericardial pressure or the intrathorarcic pressure that compromises venous return. Occurrence of cough syncope in our patient is probably due to cardiac tamponade, which manifested only during bouts of cough where raised intrathoracic pressure resulted in cardiac tamponade.

A review of literature revealed a few cases of cough syncope with pericardial diseases like constrictive pericarditis [5],[6],[7],[8],[9] and cardiac tamponade. [10],[11] In patients with large pericardial effusions, who do not have signs of cardiac tamponade, it should be appreciated that cardiac output may drop drastically during bouts of cough, sometimes leading to syncope, which responds readily to drainage of the pericardial fluid.

 » Conclusion Top

Till date, only one such case has been reported in English literature. [12] Our case is the second one and the first one from India of the rare case of cough-induced syncope in a case of pericardial effusion with complete cessation of symptoms post- pericardiocentesis. Thus, we believe that any case of cough-induced syncope needs a low threshold for investigations and a strong consideration to pericardial effusion, which may require drainage though the patient does not show tell-tale signs of cardiac tamponade.

 » References Top

1.Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA 2007;297:1810-8.  Back to cited text no. 1
2.D'Cruz I, Rehman AU, Hancock HL. Quantitative echocardiographic assessment in pericardial disease. Echocardiography 1997;14:207-14.  Back to cited text no. 2
3.Reydel B, Spodick DH. Frequency and significance of chamber collapses during cardiac tamponade. Am Heart J 1990;119:1160-3.  Back to cited text no. 3
4.Spodick DH. Threshold of pericardial constraint: The pericardial reserve volume and auxiliary pericardial functions. J Am Coll Cardiol 1985;6:296-7.  Back to cited text no. 4
5.Dhar R, Duke RJ, Sealey BJ. Cough syncope from constrictive pericarditis: A case report. Can J Cardiol 2003;19:295-6.  Back to cited text no. 5
6.Nielsen VG, Steenwyk BL, Burch TM, King CK, McGiffin DC. Hemostatic analysis of a 13 year old with antiphospholipid syndrome and restrictive pericarditis. Blood Coagul Fibrinolysis 2007;18:695-7.  Back to cited text no. 6
7.Osawa H, Takahashi W, Yoshii S, Hosaka S, Kaga S, Fukuda N,et al. Surgical treatment of 2 cases of irradiation induced constrictive pericarditis. Kyobu Geka 1999;52:1048-51.  Back to cited text no. 7
8.Hirose Y, Ishida Y, Hayashida K, Toyama T, Hamada S, Miyatake K, et al. A case of radiation-induced chronic constrictive pericarditis developing 16 years after irradiation. Kaku Igaku 1993;30:1091-6.  Back to cited text no. 8
9.Oxentenko AS, Loftus EV, Oh JK, Danielson GK, Mangan TF. Constrictive pericarditis in chronic ulcerative colitis. J Clin Gastroenterol 2002;34:247-51.  Back to cited text no. 9
10.Leimgruber PP, Klopfenstein HS, Wann LS, Brooks HL. The hemodynamic derangement associated with right ventricular diastolic collapse in cardiac tamponade: An experimental echocardiographic study. Circulation 1983;68:612-20.  Back to cited text no. 10
11.Ogimoto A, Hamada M, Shigematsu Y, Hara Y, Saeki H, Katayama H, et al. Cardiac tamponade with paroxysmal atrial flutter controlled by antituberculous therapy. Nihon Ronen Igakkai Zasshi 2004;41:112-6.  Back to cited text no. 11
12.El Osta H, Ashfaq S. Cough-induced syncope as an unusual manifestation of pericardial effusion. Kansas Journal of Medicine 2008;1:53-5.  Back to cited text no. 12


  [Figure 1]

This article has been cited by
1 Unusual presentation of pericardial effusion
Muthialu, N.
Indian Journal of Critical Care Medicine. 2014; 18(1): 49
2 Cough syncope
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Respiratory Medicine. 2013;


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