86. Case Report: Histoplasmosis Pericarditis Complicated by Cardiac Tamponade – Georgetown University

CardioNerds (Amit Goyal & Daniel Ambinder) join Georgetown University/Washington Hospital Center cardiology fellows (Nitin Malik, AJ Grant, and Tsion Aberra) for some fresh Maryland blue crab cakes at the Georgetown waterfront in Washington, DC. They discuss a rare case of histoplasmosis pericarditis complicated by cardiac tamponade. Dr. Patrick Bering provides the E-CPR and program director Dr. Gaby Weissman provides a message for applicants. Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.   Jump to: Patient summary - Case media - Case teaching - References Episode graphic by Dr. Carine Hamo The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A woman in her early 30s with a history of Crohn's disease on TNF-inhibitor therapy and chronic prednisone presented to the ED after two months of abdominal pain and fevers. She was found to have a perforated bowel and taken to emergent surgery and eventually found to have disseminated histoplasmosis. Post-surgery, her hypotension worsened. At this point, the Georgetown University Cardionerds were involved. Listen to the podcast now to learn about histoplasmosis, it's cardiac involvement, and management of acute effusive pericarditis! Case Media ABCDEClick to Enlarge A. Left: Admission chest x-ray (PA film), which was overall unremarkable. Right: Chest x-ray from hospital day 12 - which revealed pulmonary edema with bilateral perihilar haziness, increased prominence of pulmonary vascularity, and small-moderate bilateral pleural effusions. Note increased size of cardiac silhouette. At the corresponding time, pericardial effusion (without tamponade) had been diagnosed.B. EKG: Sinus tachycardia and low-voltage QRS complexes.C. CT abdomen/pelvis on hospital day 14. Free air noted within the abdomen (left). Moderate pericardial effusion also incidentally appreciated (right).D. Pulse-Wave Doppler of mitral inflow. Flow variation is present, but variation is less than <30%.E. (A) Small bowel resection showing focal mucosal ulceration, serositis, and formation of a granuloma. (B) Transmural inflammation seen on small bowel resection. (C) Pathology of ileocecectomy showing focal histoplasmosis characterized by intracytoplasmic yeast-like forms (black circles) Parasternal short axis view on echocardiogram showing a moderate pericardial effusion without diastolic septal flattening. Apical view showing profound tachycardia but without chamber collapse. Ejection fraction was moderately reduced. Parasternal short axis view on echocardiogram showing a moderate pericardial effusion with intermittent septal flattening. Apical view showing early diastolic RV chamber collapse.  Episode Schematics & Teaching The CardioNerds 5! – 5 major takeaways from the #CNCR case How does one diagnose acute pericarditis? What are the most common etiologies?Based on the 2015 ESC guidelines on pericardial disease, acute pericarditis is diagnosed when at least two of the following four criteria are present:Chest pain characteristic of pericarditisAcute onset, improves with leaning forward, pleuriticPericardial rubEKG changes consistent with pericarditisPR depressions, ST segment elevation though depending on time course these can normalize or become T wave inversionsNew or worsening pericardial effusionEtiology can vary by geography. In most developed countries, viruses are thought to be the most common cause, though even when a viral cause is suspected, the majority of cases end up being idiopathic. Other etiologies include bacterial (TB is the most common cause of pericarditis in developing countries), autoimmune, hypothyroidism, malignancy, radiotherapy-induced, and immune checkpoint inhibitor-associated