title: Low-pressure cardiac tamponade masquerading as severe sepsis diagnosed with a bedside ultrasound and as the initial presentation of malignancy.
abstract: 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.
  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.
authors.affiliation: Intensive Care Unit Director, Chester River Hospital, University of Maryland System, MD, USA ; Academic Hospitalist and Intermediate Care Unit Director, Saint Agnes Hospital, Baltimore, MD, USA.
authors.forename: Ricardo Augusto Slaibi
authors.initials: RA
authors.lastname: Conti
authors.affiliation: School of Medicine, University of Maryland, MD, USA ; Internal Medicine, University of Pennsylvania, PA, USA.
authors.forename: Ian Mandeville
authors.initials: IM
authors.lastname: Oppenheim
keywords: bedside ultrasound; cardiac tamponade; pericardium effusion; sepsis