Cardiac tamponade complicating thoracocentesis: a case for image-guided procedure

We present a case of cardiac tamponade that was precipitated by thoracocentesis and discovered at autopsy.


Introduction
Cardiac or pericardial tamponade is a life-threatening condition characterized by the slow or rapid compression of the heart by fluid, pus, blood, clots, or gas, as a result of effusion, trauma, or rupture of the heart, which has accumulated between the visceral and parietal pericardia [1]. Such compression leads to impairment of the pumping action of the heart with subsequent cardiogenic shock [2].
The fluid within the pericardial space may build up suddenly or slowly depending on the aetiology. Cardiac tamponade is a rare and serious complication of thoracocentesis (also known as pleural aspiration). Thoracocentesis is a medical procedure done by inserting a needle and sometimes a plastic catheter through the chest wall to remove fluid from the space between the lungs and the chest wall [3]. We hereby present a case of cardiac tamponade found at autopsy following left sided thoracocentesis. The role of the autopsy and its pivotal role in clinical care are further highlighted via this index case [4][5][6].

Patient and observation
A 44-year-old woman was admitted into the ward on account of three months history of cough and one-week history of fever and difficulty with breathing. The cough was insidious in onset and productive of yellow sputum that is non-bloody and non-foul smelling. The fever was high grade with associated chills and rigor.
There was associated history of progressive weight loss and drenching night sweats. There was no history of contact with person with chronic cough. Physical examination revealed a middle-aged woman who was in obvious respiratory distress. The pulse rate was

Discussion
Thoracocentesis (pleural aspiration) describes a procedure whereby pleural fluid or air is aspirated via a system inserted temporarily into the pleural space [6]. This may be for diagnostic purposes or therapeutic to relieve symptoms [6,7]. It is required in many clinical settings for variety of reasons, most especially in emergency situation [6]. Complication is very rare, however those that are commonly encountered include pneumothorax, re-expansion pulmonary oedema and haemorrhage [6,7]. Serious complication of visceral injury, like cardiac puncture, is rarely encountered [6,7]. This is quite rare but becomes very significant when it ends in fatality as it occurred as in this case [7]. In this index case, the primary pathology of the left lung, which is secondary pulmonary tuberculosis, a chronic granulomatous inflammatory condition, has caused replacement of lung tissue by fibrocollagenous tissue. This disease of the lung had significantly destroyed the lung tissue, left the lung shrunken; thereby creating a space for the enlarged heart to float inside the pleural fluid. This created a situation whereby the inserted needle caused injury to the pericardial sac and also the heart, precipitating cardiac tamponade, which eventually caused death by cardiogenic shock [2]. It is pertinent to state that the physician who performed the thoracocentesis did the procedure as a Page number not for citation purposes 3 blind procedure. A proper appraisal of the imaging procedures (Xray, CT scan etc) would have cautioned as to the possible challenges of traumatising the enlarged heart which was displaced beyond its presumed confinement. Studies and guidelines have advocated and recommended the use of image-guidance for thoracocentesis [1]. Jones et al found that the complication rate with thoracocentesis performed under ultrasound guidance is lower than that reported for non-image-guided thoracocentesis [8]. In