History and admission findings: A 62-year-old man was admitted because of recurrent abdominal pain 18 months after small cell lung cancer (SCLC) had been diagnosed and remission achieved with chemotherapy and radiotherapy. The abdomen was soft on palpation, but pressure on the epigastric region was painful. Symptomatic treatment brought improvement, but 16 hours after admission the patient complained of severe diffuse abdominal pain. Abdominal findings were unchanged. He was pale and in a cold sweat. Heart sounds were decreased, while auscultation and percussion of the lung were unremarkable.
Investigation: Lactate dehydrogenase and aspartate-aminotransferase concentrations were markedly raised and the serum creatinine was increased, while the Quick value was decreased. The electrocardiogram (ECG) showed low voltage and alternating electrical heart axis. Chest radiogram demonstrated a double-contour cardiac silhouette suggesting a large pericardial effusion, confirmed on echocardiography, which also showed a pendulum-like cardiac motion. The needle aspirate of the pericardial fluid contained malignant cells.
Diagnosis: These findings indicated malignant, hemodynamically significant pericardial effusion due to a recurrence of SCLC, with pronounced abdominal symptoms and advanced right heart failure.
Treatment and course: Pericardiocentesis brought about marked improvement. 30 mg cisplatin was injected into the pericardial sac and chemotherapy resumed. The ECG became normal. There was no tumor progression over the following 4 months when the pericardial effusion recurred, chemotherapy (4 cycles of carboplatin and etoposide) was restarted and another infusion of cisplatin undertaken.
Conclusion: This case report illustrates a not uncommon manifestation of lung cancer, malignant pericardial effusion, first becoming symptomatic as severe abdominal pain. Characteristic changes in the chest radiogram and the ECG provided the diagnosis, confirmed histologically.