Document Type

Conference Proceeding

Publication Date


Publication Title

J Gen Intern Med


CASE: A 65-year-old female with a history of CML, DMII, HTN, and HLD presented for subacute exertional dyspnea which became progressive. She had orthopnea in the absence of chest pain/fevers. She was on Imatinib for 1 month prior to presentation for newly diagnosed CML. ECG showed electrical alternans, BNP was 50 pg/mL, and troponin was 6 ng/L. TTE demonstrated an EF of 60-65% with a large pericardial effusion and signs of right ventricular diastolic collapse. Pericardial drain had 400 mL output. Repeat TTE showed resolution of effusion. She was discharged on colchicine 0.6 mg daily and ibuprofen 600mg tid. Imatinib was held. 2 weeks later, she presented for progressive dyspnea. TTE demonstrated a moderately sized pericardial effusion. The patient had repeat pericardiocentesis, requiring a pericardial window. Pericardial biopsy showed chronic pericarditis without malignant cells. Cytology of the pericardial fluid was negative for malignancy. Patient was given colchicine .6mg bid and Ibuprofen 600mg tid at discharge. Hematology/Oncology decided to start patient on Bosutinib. At follow up 2 months later (5 months after symptom onset), patient was asymptomatic IMPACT/DISCUSSION: Subacute cardiac tamponade is more subtle presentation than acute tamponade. Tyrosine kinase inhibitors can cause severe fluid retention. Severe fluid retention (pleural effusion, pericardial effusion, pulmonary edema, and ascites) was reported in 1.3% of newly diagnosed CML patients taking Imatinib and in 2-6% of other adult CML patients taking Imatinib. The medication was discontinued at initial presentation, but the effusion recurred. In general, most side effects are reversible with temporarily interrupting or stopping therapy. Correct dosing/duration of agents is essential for adequate treatment. Aspirin is dosed at 600-975mg tid-qid. Ibuprofen is dosed at 400- 800mg tid. Both medications are given for 1-2 weeks initially, and 2-4 weeks if recurrence of symptoms. Colchicine is dosed 0.5-0.6 mg bid for up to 3 months (6 months for recurrence). The patient was asymptomatic prior to diagnosis of CML, making it interesting that biopsy 6 weeks after symptom onset showed chronic pericarditis. Chronic pericarditis is defined as inflamation lasting 3 months or more. Of note, high-dose steroids have been associated with higher recurrence rates of pericarditis. CONCLUSION: Pericardial tamponade/effusion secondary to tyrosine kinase inhibitors is a previously described entity that can present as a subacute process without classic signs and symptoms of acute tamponade/ pericarditis. Traditionally, cessation of the drug was thought to be enough to prevent recurrence. Colchicine, Aspirin, or Ibuprofen are first-line agents. Steroids should generally be avoided. It is unclear if these traditional therapies are successful in treating chronic effusions associated with immunotherapy/malignancy.




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