1999 Resident Poster Competition
Rami Y. Haddad M.D.
ST. LOUIS UNIVERSITY
Pericardial Effusion: A Rare Complication of Multiple Myeloma
An 82 yr old man who was known to have multiple myeloma for more than 25 years presented with a 1 year history of shortness of breath and generalized weakness which was progressive. At the time of admission he was receiving dexamethasone but he had been treated previously with chemotherapeutic agents for myeloma. Subsequent examination of a bone marrow aspirate 3 yrs prior to admission revealed poorly differentiated multiple myeloma. Blood pressure was 120/67, pulse rate 97/min with palpable pulsus paradoxus of approximately 10 to 15 mmHg. The jugular venous pressure was not noted to be elevated and Kussmaul sign was negative. Auscultation of the heart revealed distant heart sounds with a grade II-III/VI pan-systolic murmur of mitral regurgitation. No peripheral signs of heart failure were noted (no ascites, edema). Plasma hemoglobin was 11.4 g/dL, total white cell count 6/3000/mm³ (differential count: 78% neutrophils, 6% lymphocytes, 13% monocytes) and serum creatinine 1.7 mg/dL. Total serum protein was 7.3 g/dL and albumin 2.8 g/dL. Serum protein electrophoresis showed gamma globulins 1.8 g/dL with no monoclonal peaks. Chest X ray showed bilateral pleural effusions, right greater than left and cardiomegaly. Echocardiogram revealed large pericardial effusion with notching of the right atrium consistent with cardiac tamponade. Pericardiocentesis was done and 750 ml of blood stained fluid was drained from the pericardium. Cytologic examination showed the presence of reactive mesothelial cells with a substantial proportion of plasma cells in addition to other inflammatory cells. Because of the patients age and advanced stage of disease, no additional specific therapy was given and he was offered hospice care. Over the course of the next 2 months, he was readmitted to hospital with pneumonia and respiratory distress due to a large pleural effusion. He subsequently developed renal failure and died soon thereafter.
Review of the literature reveals less than 20 other cases of pericardial effusion related to myeloma. In some of these reports, the effusion was related to the presence of amyloidosis while in others it was due to malignant infiltration of the pericardium by plasma cells as appeared to be the case in our patient.
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