Cardiac Tamponade in a Child With Fever of Unknown Origin

Abstract

An 8-year-old girl with neurofibromatosis type 1 and mild intermittent asthma presented with an 8-day history of a daily fever between 101°F and 105°F, a nonproductive cough, congestion, a sore throat, and myalgias, despite treatment with amoxicillin for bronchitis and cefazolin for a Staphylococcus epidermidis urinary tract infection. She presented on day 8 of her illness with a macular hand rash, flank pain, and strawberry tongue and was admitted for evaluation of a fever of unknown origin. She did not have any weight loss or joint pain. Admission laboratory values were notable for a white blood cell count of 26 800 cells/mm 3 with 15% bands and 74% segmented neutrophils, an erythrocyte sedimentation rate of 52 mm per hour, C-reactive protein levels of 21.5 mg/dL, ferritin levels of 1129 ng/mL, normal results from liver function tests, a respiratory virus film array with results positive for sapovirus, and sterile blood and urine cultures. She was started on empirical ceftriaxone coverage with no improvement in symptoms. Computed tomography of the head, chest, abdomen, and pelvis revealed cervical, axillary, mediastinal, mesenteric, and inguinal lymphadenopathy. A transthoracic echocardiogram showed no evidence of intracardiac vegetations but revealed a small pericardial effusion. She remained hospitalized with almost daily fevers despite antibiotics but was otherwise hemodynamically stable. On hospital day 9, the patient developed tachycardia (130-140 beats per minute), respiratory distress (tachypnea to 62 breaths per minute with accessory respiratory muscle use), hypoxemia (pulse oxygen saturation of 89%), and hypotension (77/42 mm Hg). On examination, she had nasal flaring and subcostal retractions; her lungs were clear to auscultation. She had no visible jugular venous distention (JVD), hepatomegaly, or lower extremity edema, and her heart sounds were not muffled. A chest radiograph (CXR) revealed a newly enlarged cardiac silhouette and clear pulmonary fields (Fig 1). An electrocardiogram (ECG) showed sinus tachycardia with normal axis, low voltages, and T-wave inversions in the lateral precordial leads. A repeat echocardiogram revealed a 2.2 cm circumferential pericardial effusion with right atrial collapse in diastole, increased atrioventricular valve inflow respiratory variation, and inferior vena cava plethora consistent with tamponade physiology (Fig 2).