Approach Considerations
Medical care is dictated mainly by the general condition of the patient and the underlying malignancy. It is important to remember that almost 50% of patients with symptomatic pericardial effusion and neoplastic disease have a nonmalignant cause, such as radiation-related, idiopathic, infectious (including tuberculous and fungal), and lymphatic obstruction.
Transfer pediatric patients with a pericardial effusion to a facility that provides pediatric cardiology and cardiovascular services. If a diagnosis of malignancy is suspected, immediate availability of pediatric oncologists is necessary.
Hemodynamic support is of some value until drainage of pericardial fluid can be accomplished. Pericardiocentesis and intrapericardial sclerosis are effective therapies for malignant pericardial effusions that recur. Intrapericardial administration of drugs (eg, cisplatin) can be important. Anti-inflammatory drugs may be used for viral pericarditis.
No special diet requirements are necessary. Restrict activity only to the limit of intolerance. Further outpatient care is often required to look for evidence of constrictive pericarditis.
Pericardial Drainage
In addition to its diagnostic role (see Workup), pericardial drainage is used to treat hemodynamic compromise in the presence of cardiac tamponade.
The safety and effectiveness of surgical drainage of pericardial fluid via pericardiectomy (complete or partial) or the creation of a pericardial window are well recognized. This procedure removes fluid that is excessively thick. Perform open surgical drainage if purulent pericarditis is present. Obtain biopsy specimens from the pericardium and the epicardium.
Total pericardiectomy may be required, especially in the presence of a thickened pericardium that has a constricting effect. Thoracotomy may be required to arrive at a complete diagnosis.
Pericardioamniotic shunting has been tried in fetal malignant pericardial effusion, with variable success. [9]
Consultations
The following consultations may be helpful:
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Pediatrician
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Pediatric cardiologist
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Pediatric oncologist
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Radiologist
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Nuclear medicine specialist
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Cardiothoracic surgeon
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Physiotherapist
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Occupational therapist
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Specialist nurse
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Family physician
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Plain chest radiograph from 3-month-old infant with pneumonia and malignant pericardial effusion, showing cardiomegaly and bilateral pneumonic patches.
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Two-dimensional echocardiograph from subcostal window, showing large pericardial effusion.
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M-mode echocardiograph from child with pericardial effusion.
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Cytologic features of malignant pericardial effusion. Smear of centrifuged pericardial fluid from patient with malignant pericardial involvement from lymphoma. Low-power view showing numerous mononuclear cells along with large atypical malignant cells.
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Cytologic features of malignant pericardial effusion. Smear of centrifuged pericardial fluid from patient with malignant pericardial involvement from lymphoma. High-power view showing morphologic details of malignant cells. These cells are large and show oval hyperchromatic nuclei, some of them having nucleoli. Cytoplasm is reduced to thin rim.
