T-cell Acute Lymphoblastic Leukemia Presenting as a Cardiac Tamponade

Case Report

Austin J Emergency & Crit Care Med. 2014;1(2): 4.

T-cell Acute Lymphoblastic Leukemia Presenting as a Cardiac Tamponade

El Sayed MJ1*, Gharzuddin W2, Kharfan-Dabaja MA3

1Department of Emergency Medicine, American University of Beirut Medical Center, Lebanon

2Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Lebanon

3Department of Blood and Marrow Transplantation, Moffitt Cancer Center, USA

*Corresponding author: El Sayed MJ, Department of Emergency Medicine, American University of Beirut Medical Center, PO. Box: 11-0236 Riad El Solh, Beirut 1107 2020, Lebanon

Received: December 02, 2014; Accepted: December 18, 2014; Published: December 22, 2014


Acute leukemia presenting as a clinically significant pericardial effusion or cardiac tamponade is a rare event. We report the case of a young man who presented to the emergency department with symptoms of dyspnea and hemoptysis and was found to have a cardiac tamponade as the presenting sign of a hematologic malignancy. The patient underwent a therapeutic pericardiocentesis which showed presence of lymphoblasts. A bone marrow aspiration and phenotype analysis confirmed the diagnosis of T-cell acute lymphoblastic leukemia. He was started on chemotherapy without immediate complications. Additionally, we briefly describe the approach to diagnosing pericardial effusions in complex emergency presentations by raising clinical suspicion and identifying suggestive signs on the different tests available to the emergency physician.

Keywords: T-cell; Leukemia; Pericardial effusion; Tamponade; Dyspnea


ALL: Acute Lymphoblastic Leukemia; CD: Cluster of Differentiation; CT: Computer Tomography; ECG: Electrocardiogram; ED: Emergency Department; HIV: Human Immunodeficiency Virus; LDH: Lactate Dehydrogenase; RT-PCR: Real Time Polymerase Chain Reaction; TdT: Terminal deoxynucleotidyl Transferase; TEL-AML1 (T 12,21): Fusion gene resulting from chromosomal translocation t (12,21); E2A-PBX (T 1,19): Fusion gene resulting from chromosomal translocation t (1,19); BCR-ABL (T 9,22): Fusion gene resulting from chromosomal translocation t (9,22); AF4-MLL (T 4,11): Fusion gene resulting from the chromosomal translocation t (4;11)

Case Presentation

A 27 year old male, previously healthy, presented to the emergency department (ED) with progressive dyspnea and productive cough of one week duration. His symptoms started one month prior to presentation, mainly manifesting as a non-productive cough and nasal congestion for which he received several courses of antibiotics on an outpatient basis for a presumed diagnosis of bronchitis. On further review of systems the patient reported low-grade fever, night sweats, two episodes of hemoptysis, and unintentional weight loss of 5 kg over one month duration. He denied any chest pain or skin rashes. His social history was relevant for recent travel to Africa for work without exposure to livestock or livestock products.

On presentation the patient's vital signs showed tachycardia (heart rate of 135/min) and tachypnea (respiratory rate of 22/min). He was afebrile (37°C), his blood pressure was 168/106 mmHg and his oxygen saturation was 99% on room air. His physical examination was notable for decreased breath sounds in left lower lung base and for tachycardia with a systolic ejection murmur on auscultation. The rest of the physical examination was unremarkable for palpable lymphadenopathy or organomegaly.

In the ED, the patient was placed on droplet precautions isolation, pertinent laboratory tests were ordered, and intravenous (IV) fluid resuscitation was started. Electrocardiogram (ECG) demonstrated sinus tachycardia with electrical alternans (Figure 1). Chest radiograph showed cardiomegaly and a left lower lobe lung consolidation (Figure 2). A bedside cardiac ultrasound showed pericardial effusion with mild diastolic right ventricular collapse and evidence of respiratory variation of mitral inflow velocities consistent with tamponade physiology. The ultrasound also revealed the presence of a left hilar mass. A chest CT with IV contrast confirmed the presence of a large mediastinal heterogeneous mass (11.8 x 4.4 x 4.8 cm) (Figure 3) compressing the pulmonary artery and the left main bronchus, in addition to a large pericardial effusion (Figure 4) and splenomegaly. The initial laboratory tests were notable for anemia (hemoglobin 8.6 g/dL), thrombocytopenia (35,000 /μL) and a blood film showing presence of blasts (Table 1). His coagulation profile and biochemical profile were within desirable range except for an elevated lactate dehydrogenase test (LDH 2093 IU/L).