infarction. Pleural effusion masquerading as ...

Pleural effusion masquerading as myocardial infarction. C A Manthous, G A Schmidt and J B Hall Chest 1993;103;1619-1621 DOI 10.1378/chest.103.5.1619 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/103/5/1619

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only

catheter

placement

of the

We recommend catheter be

that ascer-

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cannimlation

sheath-protected

to ensure

a surgical

being lumen

artery

during

after

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needle

became

the

the

inflation

through

space

The

cannula

the

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catheter

the

in

allows

has

not

been

should

catheter

he

chest.

P. Kmmral S, Fammehet

NI , et al. Retrograde

2

Somrg 1982;

Drimikwater o)f#{149} opti

the

DC,

This

amitegraole/retrograde

fromu

Smmrg l99(); 3 Diehil

atrial

et

Fabiamii

delivery

valve

P. Bercot alternative

sumrgery

A miewsimplilled svitiionmt

1)100)01 car(lio)plegia. EJ, ah.

trial

JN,

(‘ar(hio))lo’gia

Konstamii

Efficacy

mmmi(Iergo)ing

ramiohmmi,ized 4

in aortic

11, BmmckhergCl).

l.aks

Eichorn

RNl,

patiemits

(lehivery

a safe

Ann

right

nietboxl

heart

j Thorac

iso)latio)n: Cardiowasc

1(X):56-6()

JT,

Bojar

A, Conimimi

simums I)erf1msimm:

34:647-58

(‘ar(lio)plegic

muizimig

M, Lavergne

o’o)ro)nary

emismmrimig cardioplegic

Tliorac

cami mmumlatiomi

heart

the

instead

pierced

and

atrial

pulsatile

,

obvious

in which right

operation.

I Memiasdie

retro)perfilsiomi

vith

a case

ruptured

had

REFERENCEs

thio’

imiserte(l

artery

to) the

ae atrium,

to) leak

the

indicating an attachthe catheter was

string for retrograde cannulation. mllo)l)ihity of the pulmonary artery

for co)mil)ariso)mi,

air

this

The

not

from

to) withdraw ,

right

immediately

present

sterile

string. In

injected

sutured

checked

a l)tl5(

In

the

could

Ilowever,

attempted

had

port Vejlsted.

i)allOOn

pro)cediir’

suture.

pulmonary

snared )l(’giC

we

heart. to

the

not

cardiac

simuis Card

2

the was

taille(l

lmmmiien,

beating

the

puml-

and

returned

catheter.

the

the

distal

tracing air

flO

the

o)f the

in

Ehiasen

assuflle(l

when

end

around

This

was

We

tethered

caught

h

sumtumred

pierce(l

change

hummiien of the

and

replace

noted

the

effectively

l)t15C free

retroplegia

amiol infumsion

to) was

We

through

the syringe.

to)

planned

no

described

bypass,

was had

o)cchmsion

after

resistance

achieved

so)lumtio)nthrotmgli the

l)rt thro)ugh

can

he

can

catheter

tIme o)cclumsio)mI

additional

1S dli

l)ro’s(’r(ltio)m1

a l)alloo)n-ti)pe(l

b

includes

perfusion

ami(l

of cardioplegic

atriumm

cannumla

l)ahlo)o)m1

as

the

5115(0’

as

catheter

which

string,

There

artery

ol)tained

arteries.

artery

purse

tracing

o)cchum(le(l,

alloxved

1).

the

lunien.

artery

nient

Exaniinatiomi

liv

i)u1h111o)i1ar

be

afl(l

was transferred

pmmrse

niark

area

right

imici(lo’nt.

revealed

at the

vo)lmmmno-

reexplored

defect

The imi

‘all

l)eell

l)umhI1o)ms1r

puilniomiary

the

inflation

nionarv

(lisso)ci,o-

\‘igo)ro)mms

smmrgically

atrial

a(l(hitiofl, a larger vo)lumnle of cardioplegia o)f the mieei to) fill the right atriumn, right

proxinial

case,

balloon

iioit

1utio’mit

1)10)001 appeareol

our

the

to)

In

amii

In

l))ISC

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.

(lefeots. because

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cardiac

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mlo)te(l imi tlit’

WLS

was owersewn, O)f

anol

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vo)llmliiO’

tuho’ i)egaml

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as

inimnediatel large

. A

smmrgical msl)irate

to) OO)mitimimme lvitli(lrasv(ul

broke

rmmptmmreol

of time pro)ce(lmmre.

simico’ it miiav liavo- l)eemi

liVI)o)temisive

resumscitatio)mi

to

had

end

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miiaolo-

on atto’miiptimmg

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at the

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,

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the

after

attenipt

l)mt am,(l free

inflatiomi

tlio- l)dlh)o)mI

tlio’ catlio-ter

l)elox.’iie

A,

thiroimgh

the

Payne

l)D,

Dresdale

sinmms

retro)gra(ie

mnyo)car(hi(ul

AmimmTiiorac

.

MA,

o)f

revascumlarization: Smmrg 1988;

J,

Swansomi

right

.1

.

in

pro)spective

45:595-6()2

Carpenter

atriimm

AR,

car(lio)plegia

Retrograde

A.

Anmi Thorac

Smmrg 1986;

41:101-02 5

Shah

KB,

Taolikonda

l)umlm)lo)mi(trY artery 1984; 61:271-75 6 1 Ielemia

\V

artery

N1CKd

LKR,

RSF.

catheterizatio)n.

7 Eliasemi

P Vejlsted

tip)o’Ol

c,utlieter

Cardiov;usc

lammglihin

c,uthieterizatio)n

Analg

A mechanical

1992;

AA.

A review

of pumlmoiiarv

with

sumrgery

a l)alloon-

Scand

J Thorac

14:205

Pleural Effusion Masquerading Myocardial lnfarction* Constantii,e

Fm V moo:1 . Pmmm.st’stmimig smmtmime at 2:3 lmmniemi.

ii,

the

i)dll)

5)11

im,flatio

mi

*Fro)fli

A.

the

N1e(lio.imit’,

Sectum ITmiiversitv

as

?ol.I).;

?%f(llmthOfl.S,

A. Sclm:imidt,

(;?(‘gor!,

of

Anesthesiology

74:154-55

co)mphication

dmmrimig o)pen-heart

Smmrg 1980;

El-etr patients.

Ami immiimsmmalO’oflipliO’atiO)Ii Anesth

II.

S.

in 6245

It!.!).

,

F.C.C.?;

of I’mmlmiionary of (hicago,

(In(lJ(’.S.S(’

amid Critical

B. Hall, (are,

M.D.

Department

of

(hicago.

CHEST

I 103 I 5 I MAY,


1993

1619

caused

a substantial

myocardial

ECG

axis

CASE A 78-year-old to the

change

and

mimicked

acute

infarction.

man

University

with

REPORT

a long

of Chicago

history

of tobacco

Hospitals

after

use

3 weeks

presented

of increasing

of breath . Chest radiograph revealed a large left-sided pleural effusion (Fig 1). Pleural fluid analysis was nondiagnostic but the postthoracentesis radiograph showed a left upper lobe mass. shortness

Fiberoptic

bronchoscopy

mass

subsequently

after

the

was

bronchoscopy,

promptly

absence to topical

cocaine

Tube

given

for

was

ventilation,

chest

yielding

radiograph

drainage,

was

(Fig

2).

possibly

peaked

to aid

hours 97

IU.

discontinuation

return

of

mechanics

following

revealing

The

related

at only

Lung

Immediately

repeated,

and showed

Twenty-four

enzymes

5 L of fluid.

improved.

EGG

the

ECC

precordium infarction,

performed

Shortly

dyspneic An

bronchoscopy.

(CPK)

thoracostomy

failure.

entire

the

carcinoma.

extremely

myocardial

phosphokinase

mechanical

became

his

acute

endobronchial

cell

respiratory

across

was

ulcerating,

squamous

patient for

R waves

creatine

the

the

diagnosis

an

to be

intubated

of

working later

disclosed

proven

and

chest

tube

of R waves

(Fig

3). DISCUSSION

Pleural

effusions

physical FIGURE

1.

Portable, semiupright of respiratory failure

development effusion

and

nearly

complete

chest reveals

atelectasis

radiograph following the a large left-sided pleural of the

left

shifts

However,

lung.

since

large

not

generally

T

voltage, provoke alternans. the QRS However, patients.

that

QRS pattern,

atrial

fibrillation,

pleural

effusions

and T-wave sick sinus

can

morphology

syndrome,

Studies in animals with effusionsm2 amplitude and axis may change these phenomena have not been We report

I

a case

in which

affect

a large

the

that

pleural

axis

its

normal

left

axis

the

cause,

large

flow

on

the

in

pleural

deviation axis

suggestive

a large ruled

effusions,

ECG

than QRS

conductive

even

while

rotated, axis.’

fluid contents, the

is invoked

seen

chest.

shifted

could altering

heart to

retains

explain

in emphysema.

the

Whatever

secondary to pleural effusion may be In our patient, the loss of R waves was

to indicate subsequently

pleural

ECG,

the

change

thoracic

a mechanism

sometimes shift

rather to

of

through

through

within

is typically

effusions,

volume

surface

vectors

heart

believed

large

Such

ECG

of the

mediastinum

ofcurrent

axis.

resulting

ECG.

substantiated

the

thought this was

electrical

suggest

on

the the

underappreciated.

and can

and

one

changes,

of acute

myocardial infarction, although out. Therefore, in patients with should

consider

including

myocardial

axis

the

shift

potential

and

for

patterns

infarction.

effusion

I

rTITr[

change

QRS

entire

with

Alternatively,

assert

the

these

are

change

position

in patients

The effects of pleural effusions on the ECG have not been well studied. We report herein the case of a patient with extreme QRS axis deviation mimicking acute myocardial infarction. Thoracentesis caused the return of a more normal axis. (Chest 1993; 103:1619-21) extbooks

might

in the

TT

ii

.j-

m

v-i---

I

:i- i--r-r-

.

11Tf11hhhi1i1 -‘--

--:fT1_

I L± I

I

i:i11fj

lead

1620

1t

2. The V3 through

FIGURE

--i-

--

i_

:: #{182} : ,V:

I

before

V

-----

#{149} I I

i!

ECG V6.

:V! Y;

chest

tube

placement

shows

low

voltage

in the

Pleural

limb

leads

Effusion

and

QS

complexes

Masquerading


as Ml (Manthous,

Schmidt,

Ha!!)

.

-,

I

-

-,

.

#{149}1#{149}1 .!_

-i--t

-

.

.-.i-

.

.

3. Following

FIGURE

- .

-

drainage

ofthe

left-sided

effusion,

REFERENCES 1 Rush

JE,

in the

Hamlin

dog.

2 White

Effects

Rhode

to clinical

EA.

pleural

effusions

on QRS

9:1887-91

Correlation

disease

in the

of electrocardiographic

J

horse.

Am

Vet

Med

findAssoc

1974;

164:46-56 H.

Practical

1977;

electrocardiography.

Baltimore:

Waverly

infiltrates;

its

An Unusual Pulmonary Juan-Antonio

Jos#{233}-Angel Carretero, Alfonao

Cay,

M.D.;

Bronchiolitis

Fernando

and

obliterans

with

M.D.;

was

M.D.; M.D.

(BOOP)

spectrum

is a

as

a cavitated

pulmonary

of radiologic

solitary

BOOP

with

follows:

the

nodule.

remarkable

veolar

ducts,

*From

the

Villanova Civeira) Miguel

and Service

disease

of polyps

temporal

uniformity

alveoli; of

(Drs. Domingo, and the Service Servet (Dr. Cay),

interstitial

Internal

pneumonia

whose

presence

We

Medicine

main

(BOOP)

In

of

of

early

to the

good

due

However,

radiologic

BOOP

the

findings

whose

makes

clinical-radiologic

cavitated

think

a heating

the

that

nodule

this

justifies

diagnosis

is an the

ofthe

excep-

inclusion

pulmonary

of

solitary

the

tissue

the

al-

mononuHospital

Royo

Ferrando, and of the Hospital

to)

hospital.

hospital

admission,

production

also)

absolutely

unremarkable

following

parameters:

(albumin

44 percent;

flank

of bloxxl

analysis

calcium,

12

percent;

beta-globulins,

16.7

percent);

leukocytes,

11,800/mm3

blood

cells,

106

normal. percent;

FEV,IFVC,

FRCITLC,

percent;

and

revealed

DcoNA,

negative. and

Brucella,

serologic the

tests presence

for

were

36

urinalysis

in

107

percent

percent,

negative.

acid-fast

antibodies to and

A fiberoptic hernia

with

MEF-

TLC,

109

Dco-SB,

sputum

Nocardia,

of FEy,,

66 percent;

precipitins

Salmonella, of a hiatus

red

36 percent,

ANA,

g/dl

formula;

RV, 114 percent;

factor,

7

hematocrit, o)f the

MMEFR,

Repeated

studies

rheumatoid

g/dl;

(expressed

RVIFLC,

74 percent.

Serum

DNA,

Aspergillus monias

50 percent;

the

gamma-globulins,

FVC,

48 percent;

to)

for

proteins,

Results

tests

following:

76 percent;

MEF-75,

percent;

stranded

the

except

normal

12.4 hour.

Physical

admitted

alpha,-globulins,

and with

first

function

showed

50, 86 percent;

were

at the

Pulmonary

value)

percent;

hemoglobin,

mm

was

total

a

nisty

asthenia,

fever.

normal

mg/dl;

began

malaise,

6 percent;

16.6

3,960,000/mm3;

he

he

were

cougher.

initially

without when

alpha,-globulins,

16.7

ESR,

from

pain

fumes,

a usual

of sputa

suffered

right

He was

to copper

He was

pleuritic, Results

smoker.

exposure

hydroxide. with

He

80 pack-year

mild

the

cough

hemoptoic. were

with

sodium

prior

and

findings

and

nocturnal

finally

REPORT man,

factory

month

anorexia,

were

is

bronchioles,

inflammatory

P#{233}rez-Calvo, Carretero, of Pathologic Anatomy Zaragoza, Spain.

years

The

steroids.’’

and

a 54-year-old

acid,

percent;

characteristics

of granulation

into

was

for

and

obhiterans

bronchiohitis

organizing

lung

We

patient

predicted

obliterans

an infiltrative

case

in the differential

progressive

100

are

with

in recent

disease.2

important

a pulmonary

finding.

hydrochloric

pneumonia

a wide

ANAantinuclear antibodies; organizing pneumonia

ronchiolitis

is very

this

background

difficult.’ a

as

working

think that this finding may justify the inclusion of BOOP in the differential diagnosis of the pulmonary solitary nodule. (Chest 1993; 103:1621-23)

B

quite

published

in

it is treated

present

The

features. Usually, these are bilateral, patchy, alveolar, or ground-glass infiltrates, but other presentations have also been described. We present a case in which the radiologic appearance

of cases

general

nodule.

P#{233}rez-Calvo,

Civeira,

organizing

disorder

pulmonary

of the

CASE

M.D.; Juan-lgnacio M.D.; Juan Ferrando,

Domingo,

precordium.

in its clinical

diagnosis

BOOP

entire

interest

of BOOP

presentation

of Solitary

Cause Nodule

number

ofspecificity

tional

the

preservation

clinical

when

We

Bronchiolitis Obliterans Organizing Pneumonia*

and

shows the recognition lack

38

across

architecture.’ The growing

prognosis

3 Marriott Press,

are apparent

clear

ofgraded

J Vet Res 1985;

Am

NA,

ings

RL.

R waves

112 smears

to) doubleCandida atypical

and pneu-

gastrosco)py

gastroesophageal

reflux. Chest

radiography

(Fig

1), tomographs;

CHEST


I 103

and

computed

I 5 I MAY,

1993

tomo-

1621

Pleural effusion masquerading as myocardial infarction. C A Manthous, G A Schmidt and J B Hall Chest 1993;103; 1619-1621 DOI 10.1378/chest.103.5.1619 This information is current as of July 13, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/103/5/1619 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
