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A Dramatic Heart and Lung Problem�

Majid Sadigh, MD

Alex Kayongo MBChB, MSc., PhD

Immunology Fellow 

Global Infectious Diseases Research Fellow 

Makerere University College of Health Sciences in collaboration with Rutgers, The State University of New Jersey, USA School of Biomedical Sciences Department of Immunology and Molecular Biology

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We owe a debt of gratitude to patients and their families for letting us sharing their stories and photos.

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Objective

�To become familiar with the most challenging aspects of practicing medicine in resource scarce settings, both from the perspective of locally trained and internationally trained physicians.�

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Patient information:�

A young Muslim man, a student from central part of Uganda presented with difficulty breathing X 1 week, with swelling, weakness and fevers.

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History of Present Illness�

The patient reported feeling well until about a month prior to admission when he developed malaise associated with low grade fevers and chills, plus occasional rigors that worsened in the evenings. Over a two weeks’ time period, the fevers became persistent and were associated with drenching night sweats, appetite loss and significant weight loss.

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  • At the same time, he developed a non-productive cough associated with a pleuritic retrosternal chest pain and progressive difficulty in breathing such that he could only breathe while seated upright in bed.
  • He reported lower legs swelling.
  • He also reported abdominal swelling and pain.
  • First, he was admitted to another hospital but due to failure of improvement on antibiotics and antimalarials he was transferred to Mulago.

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History of Present Illness�

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Questions.�

  • Is there anything else you would want to know about this patient’s history?

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  • Which focused clinical examination would you do?�

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Physical Examination�

  • Vitals: HR 130s BP-100/50 RR-30 bpm. SpO2 80% at room air
  • Pulsus Paradoxus: more than 25 mm of mercury
  • General: Young adult male, ill appearing. Seen leaning forward in bed with his face supported by his left hand, off oxygen.
  • Neck: Distended neck veins; +JVD; HJR; Not possible to evaluate.
  • Cardiovascular: Thin and thready radial pulse. Decreased pulse strength during inspiration. Apex beat non-palpable, distant heart sounds.

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  • Respiratory: In severe respiratory distress, using accessory muscles for breathing, with tachypnea of 30 bpm. Visible intercostal and subcostal recession on inspiration, lack of breath sounds bilaterally. Dull percussion note bilaterally.
  • Abdomen: Mildly distended abdomen, with mild to moderate right upper quadrant tenderness, no guarding, bowel sounds heard.
  • Lymph: Bilateral axillary and supraclavicular adenopathy
  • Neuro: Alert and oriented x3; interactive with examiner. Speech fluent.

Physical Examination�

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Questions.�

  • What are your impressions?

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Assessment & Differential Diagnoses�

Cardiac Tamponade

    • Uremic or malignant pericardial effusion with cardiac tamponade
    • CTD
    • TB
    • Pyogenic
    • Viral

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Questions.�

  • What investigations would you order for?

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Labs

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  • Blood workup-CBC/LFTS/Chemistries ordered
  • HIV: Negative
  • EKG: low voltage
  • CXR
  • ECHO

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  • Partially loculated large pericardial effusion with compression of the right atrium.
  • The ventricular chambers are small.
  • A left pleural effusion is evident.
  • Pericardium is markedly thickened and has calcification.
  • The pericardium is also adherent to the right ventricular surface which means this would likely be an effusive constrictive pericarditis.

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Management Plan�

  • Place patient in cardiac position
  • Provide supplemental oxygen by nasal cannula
  • Perform urgent bedside attempt at thoracentesis
  • Perform urgent bedside attempt at pericardiocentesis
  • Surgical consult for emergency pericardial window

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��Decision making and practicing medicine in a resource limited setting�

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Challenges

  • Limited human resources
  • Limited resources (equipment, supplies and technology)
  • Emotional strain from  observed system iniquities
  • Psychological torture, having all the knowledge but failing to help  poor patients for luck of what it takes in the medical system
  • Terminally ill patients�