Cough as the sole manifestation of pericardial effusion

A 59-year-old woman with paroxysmal atrial fibrillation (AF) presented with severe non-productive cough, malaise, low-grade fever and AF flare-up 3 weeks following pulmonary vein isolation with radiofrequency catheter ablation. She denied chest pain or dyspnoea. Patient was haemodynamically stable. There was no pulsus paradoxus. Laboratories showed leucocytosis and elevated C-reactive protein. ECG showed sinus tachycardia. CT abdomen and pelvis showed a large pericardial effusion (PE). Shortly after admission, she developed AF with rapid ventricular response, responsive to intravenous amiodarone. Transthoracic echocardiogram revealed 2.4 cm posterior PE without tamponade physiology, non-amenable to pericardiocentesis via sub-xiphoid approach. Patient underwent left thoracoscopic pericardial window with removal of 250 cc bloody fibrinous fluid. Cough improved significantly and she was discharged on oral amiodarone and apixaban. Repeat CT chest after 2 weeks for recurrent cough showed a small PE, treated with oral prednisone for suspected postablation pericarditis, with complete resolution of cough. Amiodarone was stopped without recurrence of AF.