A patient with pulseless extremities: an unusual manifestation of cardiac tamponade

We describe a 51-year-old man who came to our institution with cold cyanotic extremities. He was receiving radiation therapy for adenocarcinoma of the lung and superior vena cava syndrome. Findings on initial physical examination were notable for absent peripheral pulses and increased jugular venous pulsations. Shortly after admission, the patient experienced severe dyspnea and tachypnea. Arterial blood gas studies revealed mild metabolic acidosis. A chest roentgenogram showed an enlarged cardiac silhouette and the known mass in the right upper lobe of the lung. An electrocardiogram demonstrated no evidence of ischemia but low-voltage QRS complexes. An emergency echocardiogram disclosed a large pericardial effusion and evidence of hemodynamic compromise. With use of echocardiographic-guided pericardiocentesis, 600 ml of bloody fluid was removed; the pulses were immediately palpable in the patient's extremities. Although symptoms associated with the extremities are unusual as the initial complaint of patients with cardiac tamponade, we illustrate several key physical findings and abnormal results of laboratory test characteristic of this disorder. In addition, we underscore the importance of considering this diagnosis, especially in patients with a malignant tumor, and we describe the prompt response to therapy.