Differential Diagnosis, Investigations and
Treatment
The differential diagnoses considered at presentation were cardiac
tamponade, acute coronary syndrome and hyperkalemia.
Electrocardiography revealed a prolonged PR interval with tall T waves.
The serum potassium was 6.6 mmol/L and serum creatinine was 10.2 mg/dL.
Cardiac enzymes were not elevated and transthoracic echocardiography
revealed moderate pericardial effusion, not in tamponade, with dilated
inferior venacava, normal left ventricular systolic function, mild
concentric left ventricular hypertrophy, grade II left ventricular
systolic dysfunction with no clots or vegetations (Figure 1). D-dimer
was elevated to 5 mcg/ml from a baseline of 0.9 mcg/ml.
She underwent emergency hemodialysis through a right internal jugular
vein hemodialysis catheter for refractory hyperkalemia, associated with
arrhythmia and hemodynamic instability. Her condition gradually improved
over the next 48 hours with a return to sinus rhythm with blood pressure
of 130/70 mm of Hg.
Two days later vascular surgeons attempted to salvage the AVF by manual
manipulation. Under local anesthesia, milking was attempted to salvage
the fistula through a venous incision. A thrombus 0.5 X 0.5 cm was
removed. Although a thrill was appreciated after the procedure, she
acutely developed shortness of breath with a continuous cough followed
by gradual drop in SpO2. Oxygen requirements increased from nasal prongs
to Venturi mask with FiO2 0.6. She became drowsy and was intubated in
view of her worsening respiratory distress and shifted to the intensive
care unit (ICU). She had sinus tachycardia of 130/m, BP was 90/60 mm of
Hg with support of noradrenaline, SpO2 was 89% with FiO2 70%.
An acute coronary event and pulmonary embolism were the diagnoses
contemplated. Electrocardiography showed sinus tachycardia.
Echocardiography showed no regional wall abnormalities and there was no
tamponade. Troponin I was elevated. A CT-pulmonary angiography was done.
Findings included completely occluding thrombosis in ascending,
descending branches of right and descending branch of left pulmonary
artery with moderate pericardial effusion and dilated inferior venacava
and hepatic veins (Figure 2 Plate A and Figure 2 Plate B).
Treatment was initiated with 60 mg of Enoxaparin Q24h, in view of her
CKD. Over the next few hours, her vasopressor requirement gradually came
down, repeat echocardiography did now show any cardiac dysfunction
except for the effusion and it was concluded there was no need for
thrombolytic therapy.