Telemedicine-Guided Pericardiocentesis for Cardiac Tamponade in Primary Mediastinal Large B-cell Lymphoma

Pericardial effusion has infectious, inflammatory, neoplastic, traumatic, cardiac, vascular, and idiopathic causes. When effusion accumulates rapidly enough to compromise ventricular filling, cardiac tamponade develops and becomes a life-threatening emergency requiring urgent drainage, a procedure conventionally performed by a cardiologist or cardiothoracic surgeon and rarely available on site at rural or resource-limited hospitals. Malignant pericardial effusion is most often attributed to lung and breast carcinoma, while lymphoma is the leading hematologic cause. Tamponade as the presenting feature of non-Hodgkin lymphoma, however, is distinctly uncommon. We describe a 40-year-old man from a rural community in Nuevo León, Mexico, with three weeks of intermittent chest tightness, diaphoresis, unquantified fever, and approximately 7 kg of unintentional weight loss, followed by progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. He presented to a rural hospital with jugular venous distension, muffled heart sounds, and lower-limb edema, without pulsus paradoxus. Echocardiography demonstrated a severe pericardial effusion measuring up to 4.6 cm with tamponade physiology. With no cardiologist on site and hemodynamic collapse imminent, an internist performed pericardiocentesis under real-time telemedicine guidance from a cardiologist, draining serosanguineous fluid whose biochemical profile suggested tumor involvement. Contrast-enhanced chest computed tomography at the referral center revealed a 14.4 × 11.8 × 11.3 cm anterior mediastinal mass with necrotic areas. Video-assisted thoracoscopic surgery allowed pericardial window creation and tumor biopsy, which established a CD20-positive primary mediastinal large B-cell lymphoma (PMBCL). Chemotherapy with R-CHOEP (rituximab, cyclophosphamide, doxorubicin, vincristine, etoposide, and prednisone) was initiated, with resolution of hemodynamic instability and no recurrence of tamponade during the reported follow-up. This case illustrates that malignancy warrants early consideration in unexplained tamponade and that real-time telemedicine guidance may allow a non-specialist physician to undertake a life-saving bedside procedure where specialist care is otherwise unavailable, an approach that merits further evaluation in rural and underserved settings.