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Peer Reviewed

Photoclinic

Diaphoresis, Dyspnea, and Discomfort: An Unusual Case of Epstein-Barr Virus-Associated Pericardial Effusion With Cardiac Tamponade

Shannay Bellamy, MD1 • William Ott, MD1Muhammad Ahmad Shahid, MD1 • Muzzamil Khan, MD1 • Richen Jirel, MD1

A 57-year-old man presented with a 1-day history of substernal chest pain, diaphoresis, palpitations, and lightheadedness while walking his dog.

History. He initially attributed his symptoms to a panic attack, however, his chest pain gradually worsened, prompting him to present to the emergency room. He reported a 1-month history of dyspnea on exertion but denied any prior history of chest pain, leg swelling, orthopnea, or paroxysmal nocturnal dyspnea.

His medical history was significant for polysubstance abuse with cocaine and alcohol, hypertension, hyperlipidemia, and panic disorder. He reported a 30-year history of cocaine insufflation and last used 2 days prior. He had a history of binge drinking alcohol every weekend, with the last drink 6 days prior. He had no history of cardiac disease or thrombotic events. He denied any other recent fever, respiratory, or gastrointestinal symptoms.

On presentation he had a blood pressure of 230/137 mm Hg, a heart rate of 122 beats/min, a respiratory rate of 20 breaths/min, a temperature of 98.1ºF, and an oxygen saturation of 96% on room air. A physical examination was significant for tachycardia with a regular rhythm, jugular venous distension, and decreased air-entry and crackles in the bilateral lung bases. There was no lower extremity edema. Laboratory investigations were significant for thrombocytopenia of 107x103/L and elevated high-sensitivity troponin of 142 ng/dl (reference range 3.0 – 53.0 ng/dl). His urine drug screen was positive for cocaine. An electrocardiogram (EKG) showed sinus tachycardia with a rate of 111 beats/min with ST ischemic changes in leads aVL and V1 and ST depressions in I and V6 (Figure 1).