Hemorrhagic cardiac tamponade presenting as isolated exertional dyspnea in an otherwise healthy individual: A diagnostic challenge

Abstract

Abstract

Background: Pericardial effusion presents with a wide clinical spectrum, ranging from incidental findings to life-threatening cardiac tamponade. Hemorrhagic pericardial effusions (HPE) are most associated with malignancy, autoimmune conditions, and tuberculosis; however, idiopathic cases are rarely reported and can pose diagnostic challenges.

Case Summary: We report the case of a 57-year-old female presenting with progressive dyspnea, orthopnea, and dry cough. Echocardiography revealed a large pericardial effusion with tamponade physiology, prompting urgent pericardiocentesis with drainage of 800 mL of hemorrhagic fluid. Extensive infectious, malignant, and autoimmune workup was unrevealing, and pericardial biopsy showed no evidence of malignancy or infection. The patient was managed empirically for pericarditis with NSAIDs and colchicine. At a two-month follow-up, she demonstrated clinical and echocardiographic improvement without evidence of constrictive physiology.

Conclusion: Idiopathic hemorrhagic cardiac tamponade, although rare, must be considered when common etiologies are excluded. Timely recognition and intervention are critical to patient survival. Comprehensive evaluation and long-term follow-up remain essential to guide management and monitor for recurrence.

Keywords: Pericardial tamponade, hemorrhagic pericardial effusion.

Key Clinical message

Pericardial tamponade may present subtly without Beck’s triad. In hemorrhagic effusion, infection, autoimmune diseases, and malignancy should be ruled out. If the workup is negative, we suggest empirical treatment for acute pericarditis.