Ubuntu #1: Not another tachypnoeic pregnant patient!
Guest Author: Dr Neville Vlok | Editor: Dr Katya Evans
History
- Mrs V is a 35 year old G3P2 female at 32 weeks pregnant by dates. She was referred to Ubuntu hospital for IVI antibiotics after being seen at the local clinic with a diagnosis of “severe pneumonia”.
- Complaints: dyspnoea & cough x 10 days – already receiving her second course of oral antibiotics.
- Background: she admits that she is sharing not only cigarettes, but also illicit smoked drugs (methamphetamines) with someone that has active pulmonary tuberculosis. Previous encounters with healthcare services included 2 previous uncomplicated vaginal deliveries & a stab wound to the left chest which required an intercostal-drain.
Examination
SaO2 95% | BP 96/56mmHg | HR 119bpm | Temp 36*C | RR 25bpm
Whilst looking at Mrs V you notice that personal hygiene is poor, she appears acutely ill and significantly distressed.
“Not another substance-abusing woman in labour” you think whilst the melody of moans, groans & monitor-alarm overtones fill the hospital.
- Obstetric & abdominal exam: non-significant with the uterus size corresponding with the 32 weeks given as history.
- Resp exam: decreased air entry in the lower left zone
- CVS: low-output status is suspected – pulse is noted to be of low volume, rapid with cool peripheries & soft cardiac tones. Jugular veins are distended
- Calves: soft, which is reassuring
Investigations:
Chest X-ray
Note: Globular heart with increased cardio-thoracic ratio. (Also note: X-ray being held up against window in true Ubuntu Hospital style due to lack of functional X-ray viewing box / electronic X-rays.. gives clue as to developing world location of patient..)
12 Lead ECG
Notice the electrical alternans in V2, attributed the heart swinging around in the pericardium.
Point of care ultrasound
You grab the ultrasound & start scanning for any clues that might help. You expected a large, dilated, obstructed right heart, because pulmonary embolism just seems to be the obvious diagnosis. You don’t see any pulmonary pathology or even a small pleural effusion you were hoping for. You do a quick subcostal view to look at the heart and pericardium and see this surprising finding.
Management
Yes! You diagnose your first cardiac tamponade at Ubuntu hospital and with a quick, perfectly placed stab of a largebore-needle under ultrasound guidance another life is saved in Ubuntu Hospital!!!
Diagnosis
- Working at Ubuntu Hospital your number 1 differential is TB pericarditis as you acknowledge the major difference in the aetiology of pericardial effusion in developed vs developing countries.
- TB accounts for 69% in developing countries compared to only 4% in developed!
Outcome
- After pericardiocentesis – admitted to the obstetric highcare unit for cardiovascular & fetal monitoring.
- Diagnosis of HIV infection was made with a CD4 count of +/-500 & high viral load.
- Whilst awaiting culture & biochemistry of pericardial fluid she was started on standard 4-drug TB regimen as well as 10mg Prednisone on advice of the cardiologists.
- Day 4: Her stay was uncomplicated & she spontaneously went into labour, she delivered a healthy female infant via C-section with no complications.
- Day 6: discharged from the highcare to the ward.
- She was kept for another 14/7 of observation in the medical-obstetric ward, discharged with no recurrence of the tamponade, only a small residual uncomplicated effusion.
- 3 sets of sputum were negative for TB (?poor technique/non productive cough), as well as TB culture from the pericardial fluid. Cytology revealed scanty atypical cells of uncertain origin. Thus the diagnosis of TB not microbiologically proven, but favourable response on anti-tuberculous treatment prompted a 9 month course of TB treatment.
Dr Neville Vlok
2nd year intern in Johannesburg.
Budding critical care physician
Other interests: prehospital emergency medicine, PoCUS, photography, travel & a good bottle of red wine.
