Primary Lung Adenocarcinoma Presenting as Cardiac Tamponade in a 40-Year-Old Non-Smoker

Lung cancer is the number one cause of cancer-death in the world with the majority of cases directly attributable to smoking. The diagnosis is mostly made following evaluation for either an incidental lung nodule or respiratory signs and symptoms such as cough and hemoptysis. This is a review of a young never-smoker who presented predominantly with gastrointestinal symptoms, which is an uncommon initial presentation of lung cancer associated with malignant pericardial effusion. A 40-year-old male without a history of smoking presented with epigastric pain associated with nausea and vomiting. He denied significant cardio-respiratory or systemic symptoms. Physical examination was unremarkable besides tachycardia of 111 beats per minute, blood pressure of 108/65 mmHg, and mild generalized direct abdominal tenderness. EKG showed electrical alternans. CXR demonstrated a prominent cardiac silhouette leading to evaluation with echocardiography, which revealed a large pericardial effusion and signs of cardiac tamponade. 1200 ml of serosanguinous fluid was removed by pericardiocentesis with significant clinical improvement. The basic workup of infectious and immunologic causes was negative, which prompted a contrasted CT scan of the chest. This revealed a left upper lobe mass measuring 3.6 x 2.8 cm without mediastinal or hilar lymphadenopathy. CT-guided biopsy was performed and was consistent with pulmonary adenocarcinoma but was negative for molecular drivers and programmed cell death ligand 1 (PD-L1). Pericardial fluid cytology also confirmed the presence of malignant cells. The patient complained of mild dyspnea and chest pain before discharge which led to a repeat echocardiogram and identification of a recurrent large pericardial effusion. Cardiothoracic surgery consultation was obtained, and the patient underwent subxiphoid pericardial window placement. Learning points from this case report include: First, non-smoking-related lung cancer is still among the top ten causes of cancer death in the US. It should remain in the differential diagnosis of patients presenting with pertinent signs and symptoms, even in non-smokers. Secondly, malignancy, most importantly primary lung cancer, is a common cause of a large symptomatic pericardial effusion in patients who have a non-revealing basic workup. In such patients, a detailed evaluation for undetected underlying malignancy is important. Thirdly, colchicine and non-steroidal anti-inflammatory drugs are commonly used for the treatment of painful malignant pericardial effusion; however, there is a lack of data to support this practice. Finally, pre-discharge screening echocardiography in patients with new or recurring cardiorespiratory symptoms following initial pericardiocentesis could be important because recurrent large pericardial effusion is a common and potentially fatal complication of malignant pericardial effusion.