A case of primary lung malignancy presenting as pericardial effusion with associated localised Epstein-Barr virus infection or persistence.

Editor,

Acute pericarditis and pericardial effusion has many causes including infections, malignancy, collagen vascular disease, autoimmune diseases, uraemia, myocardial infarction, trauma, surgery, medications and hypothyroidism.We report a rare case in which pericardial fluid was positive for both malignant adenocarcinoma cells and PCR positive for Epstein-Barr virus.

Case report

We report the case of 44 year old male mechanical engineer admitted with two weeks history of lethargy, malaise, vomiting, breathlessness and two episodes of syncope. There was no previous history of cardiorespiratory disease and he was a non smoker. On examination he was tachycardic, hypotensive and had elevated jugular venous pressure. On auscultation heart sounds were muffled with no murmur or pericardial rub heard. Chest X-ray showed cardiomegaly, (Fig 1), whilst ECG showed sinus tachycardia with no significant ST or T wave changes. A transthoracic echocardiogram showed large pericardial effusion with right atrial and ventricular collapse (Fig 2). These features suggest he was in cardiac tamponade. A pigtail catheter was inserted and 1550ml of frank haemorrhagic fluid was drained subxiphoidally.

Fig 1

Fig 2

Pericardial fluid was analysed as per guidelines for diagnosis and management of pericardial diseases of European Society of cardiology. Pericardial fluid was positive for Epstein-Barr virus on polymerase chain reaction while polymerase chain reaction for Epstein-Barr virus from leucocytes in circulation and IgM antibodies for Epstein-Barr virus antigens were negative, consistent with localised pericardial presence of Epstein-Barr virus1.

Further study on pericardial fluid revealed malignant epithelial cells with morphology suggestive of adenocarcinoma. Immunohistocytochemistry was positive for CK-7, CEA, TTF1, EMA, and weakly positive for CKS, CK-6, and Ber EP4 and negative for HMBE1, PSA, HMB 45 and CK-20. In summary TTF-1 and CK-7 being positive was highly specific of lung primary2. TTF-1 is a lineage marker for tumour arising from peripheral airway or alveolar epithelium and has no prognostic relevance3.

Chest X-ray after therapeutic drainage of pericardial fluid showed two opacities in right middle and lower zones. A computerised tomographic scan of the chest and abdomen revealed marked right hilar lymphadenopathy and a further nodal mass just below the right carina. A 1.7cm speculated mass was seen in the right upper lobe adjacent to the horizontal fissure with a little fluid in the fissure and surrounding consolidation. There were bilateral pleural effusions and further pleural-based lesion in the right lower lobe. Based on clinical and radiological findings the tumour was staged T1 N1 M1. An incidental finding of the presence of pulmonary thromboembolic disease bilaterally extending into 3rd pulmonary division was also seen and hence the patient was started on a therapeutic dose of low molecular weight heparin. The patient was referred to oncology for further treatment

Discussion

Pericardial inflammation and effusion due to Epstein-Barr virus infection is rarely reported. There are a few case reports of Epstein-Barr virus causing adenocarcinoma lung especially in Asian populations4. Malignant pericardial effusion and localised presence of Epstein-Barr virus can be explained either by malignancy secondary to Epstein-Barr virus infection5,6 or due to co-existing infection, thus making this a very rare case. It has been proposed that viral load estimation from malignant cell and non-malignant cell would have proved the causative role of Epstein-Barr virus4. As identification of causative role of Epstein-Barr virus has no implication in treatment or prognosis tissue biopsy and viral load estimation was not attempted.