Pericardial Effusion Worm-Like Strands on Transthoracic Echocardiogram

Background: Fibrinous Pericardial Effusion is the accumulation of excess fluid in the pericardial fibroelastic sac. It can be a symptom of any pathological process that affects the pericardium from acute pericarditis to systemic disorders. This broad differential poses a diagnostic challenge in the setting of acute fluid accumulation. Case Presentation: A 50-year-old male with a past medical history of extensive intravenous drug use complicated by bacteremia and left ankle abscess formation presented to the Emergency Department complaining of mild-moderate chest pain for four days. Within the last month, he presented to the Emergency Department three times for similar symptoms; however, he eloped each time before receiving proper medical treatment. Chest x-ray revealed an enlarged cardiac silhouette, and follow-up computed tomography (CT) scan demonstrated a large transudative pericardial effusion, bilateral lower lobe consolidation, and retroperitoneal lymphadenopathy. Prior to pericardiocentesis, a transthoracic echocardiogram was performed that revealed intrapericardial adhesions with a larva-like appearance. His clinical course was complicated by a concurrent left ankle abscess managed by podiatry. He received a pericardial window procedure one week later. Blood cultures from both procedures were negative, and the etiology was determined to be idiopathic. Subsequently, the cardiothoracic surgery team signed the patient off to the primary medical team for further medical management. Discussion/Conclusions: This case illustrates that imaging results can create a disproportionately severe clinical picture. Additionally, even in the case of explained systemic disease, the idiopathic nature of this patient presentation complicates the post-pericardiocentesis management of this patient. The extent of intrapericardial adhesion density and clinically severe appearance is not indicative of a pericardial effusion’s etiology. Transthoracic echocardiogram alone does not have a significant role in the formulation of a differential diagnosis for the treatment of fibrinous pericardial effusion