Pulmonary embolism with haemorrhagic pericardial effusion and tamponade: a clinical dilemma

The synchronous presentation of a patient with pulmonary embolism (PE) and haemorrhagic cardiac tamponade is uncommon and presents a therapeutic dilemma. Both conditions can be life-threatening and require opposing management strategies. The authors report a 50-year-old woman who presented with abdominal symptoms and subsequent rapid development of dyspnoea and cardiogenic shock. Investigations demonstrated bilateral segmental PEs and a large pericardial effusion causing cardiac tamponade. This large blood-stained effusion was drained urgently. She developed acute kidney injury and acute hepatic injury with synthetic failure. She was initially deemed unsuitable for anticoagulation so an inferior vena cava filter was placed to minimise risk of further PE. When no early re-accumulation of pericardial fluid occurred, a heparin infusion was started to treat the PEs. Pericardial fluid cytology was suggestive of metastatic carcinoma, with the immunophenotype most consistent with metastatic non-small cell lung cancer. She was subsequently treated with the tyrosine kinase inhibitor, erlotinib.