Low-pressure cardiac tamponade masquerading as severe sepsis diagnosed with a bedside ultrasound and as the initial presentation of malignancy

OBJECTIVE We report a patient with low-pressure cardiac tamponade masquerading as sepsis and as the initial presentation of malignancy. A quick diagnosis was done by the intensivist performing a bedside ultrasound. BACKGROUND The diagnosis of low-pressure cardiac tamponade is a challenge because the classic physical signs of cardiac tamponade can be absent. It is made even more challenging when the vital sign changes and physical examination findings mimic severe sepsis. One of the benefits of a bedside ultrasound in the assessment of a patient with an initial diagnosis of severe sepsis or septic shock is the rapid diagnosis of cardiac tamponade if it is present. DATA SOURCE AND SYNTHESIS A 55-year-old male presented to the emergency department with weakness, cough, and syncope. His examination was notable only for dusky mottling of his cheeks, chest, and neck. Specifically, there was no jugular venous distension or pulsus paradoxus. A chest radiograph showed a right upper lobe infiltrate, whereas his electrocardiogram showed only sinus tachycardia. His white blood cell count and lactic acid were elevated. The sepsis protocol was started and a bedside ultrasound revealed signs of cardiac tamponade. The patient immediately improved after a pericardiocentesis. Analysis of the pericardial biopsy revealed adenocarcinoma, later determined to be from a pulmonary primary source. CONCLUSIONS Because low-pressure cardiac tamponade is life-threatening and difficult to diagnose, evaluation of the pericardium with a bedside ultrasound should be considered in patients with syncope, severe sepsis, or shock.