CHEST Guidelines-A-Man-in-His-60s-With-Circulatory-Collapse

A-Man-in-His-60s-With-Circulatory-Collapse_chest

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A man in his 60s presented to the emergency department with shortness of breath and substernal chest pain. He had a history of compensated cirrhosis due to chronic hepatitis C and diabetes mellitus. Upon admission, his systolic blood pressure was 60 mm Hg, heart rate 110 beats/min, and he was afebrile; a saline infusion improved his blood pressure. Initial tests, including a CT angiogram and chest X-ray, were unremarkable, ruling out pulmonary embolism and aortic dissection. <br /><br />The patient later deteriorated, becoming hypotensive and lethargic, leading to his admission to the medical ICU (MICU). He was intubated, and a norepinephrine drip started. Blood tests indicated worsening leukocytosis, acute kidney injury, transaminitis, and lactic acidosis. An ultrasound study in the MICU showed a moderate pericardial effusion absent on earlier scans, suggesting progression to cardiac tamponade. Based on these findings, a pericardiocentesis was performed, draining 800 mL of purulent fluid. Tests confirmed methicillin-sensitive Staphylococcus aureus in the fluid.<br /><br />Despite intervention, the patient developed multi-organ failure from a disseminated staphylococcal infection and passed away on hospital day 5. This case illustrates the rapid progression from pneumonia and septic shock to purulent pericarditis leading to pericardial effusion and cardiac tamponade, highlighting the importance of repeated echocardiograms in managing undifferentiated shock and the potential complications of underlying infections.

Keywords

shortness of breath

substernal chest pain

compensated cirrhosis

cardiac tamponade

pericardial effusion

methicillin-sensitive Staphylococcus aureus

septic shock

pericardiocentesis

multi-organ failure

undifferentiated shock