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LETTER TO EDITOR
Year : 2016  |  Volume : 31  |  Issue : 4  |  Page : 317-318  

Unexpected detection of pericardial effusion on myocardial perfusion scintigraphy


1 Department of Nuclear Medicine, PGIMER, Chandigarh, India
2 Department of Cardiology, PGIMER, Chandigarh, India

Date of Web Publication19-Sep-2016

Correspondence Address:
Ashwani Sood
Department of Nuclear Medicine, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.187469

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How to cite this article:
Malik D, Sood A, Parmar M, Bahl A, Sood A. Unexpected detection of pericardial effusion on myocardial perfusion scintigraphy. Indian J Nucl Med 2016;31:317-8

How to cite this URL:
Malik D, Sood A, Parmar M, Bahl A, Sood A. Unexpected detection of pericardial effusion on myocardial perfusion scintigraphy. Indian J Nucl Med [serial online] 2016 [cited 2019 May 19];31:317-8. Available from: http://www.ijnm.in/text.asp?2016/31/4/317/187469



Sir,

We report unexpected detection of pericardial effusion during 99m Tc-methoxyisobutylisonitrile myocardial perfusion scintigraphy (MPS) in a patient with end-stage renal disease on hemodialysis. A 54-year-old diabetic and hypertensive male patient having end-stage renal disease on hemodialysis for the last 15 years was referred for MPS as a part of perioperative evaluation for renal transplant surgery. He had complaints of dyspnea on exertion and occasional palpitation for the last 1 month without any history of chest pain or orthopnea. The patient's physical examination was grossly normal, except periorbital edema and dyspnea on the day of MPS. Echocardiography done 1 month prior to MPS revealed severe concentric left ventricular hypertrophy, diastolic dysfunction without any regional wall motion abnormality/pericardial effusion/structural abnormality (ejection fraction ~45%).

A single day standard stress/rest 99m Tc-sestamibi MPS was performed using adenosine as pharmacological stress agent. The planar projection images in both stress and rest studies showed severely reduced tracer uptake surrounding whole of the myocardium in the shape of a halo [Figure 1] and [Figure 2] and increased translational motion on gated single photon emission computed tomography (SPECT) images. The finding of halo around the heart was suspicious of pericardial effusion and subsequent two-dimensional echocardiography confirmed the diagnosis of pericardial effusion. The echocardiography revealed large fluid collection ranging from 2 to 4.5 cm surrounding the heart along with early diastolic right atrium collapse without any evidence of diastolic collapse of the right ventricle excluding cardiac tamponade [Figure 3].
Figure 1: (a and b) Stress and rest planar projection images showing a thick “halo” of diminished tracer concentration surrounding the heart

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Figure 2: Stress and rest short axis, vertical long axis, and horizontal long axis tomographic images showing the “halo of reduced tracer uptake” surrounding the heart

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Figure 3: (a and b) Transthoracic two-dimensional echocardiography images obtained at late systole showing a large pericardial effusion surrounding the heart (PE: Pericardial effusion, LV: Left ventricle, RV: Right ventricle)

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Pericardial effusion is characterized by abnormal fluid accumulation in the pericardial cavity. The dyspnea is the most common symptom although degree of symptomatology does not necessarily correlate with the size of the effusion.[1] Echocardiography is the imaging modality of choice for the diagnosis of pericardial effusion and helps in identifying the myocardial dysfunction. It is sensitive, suitable in unstable patients and performs rapidly.[2] The chest X-ray for pericardial effusion shows increased cardiac silhouette known as “water bottle heart” while CT scan may help in detecting the minimal pericardial effusion.[3]

MPS is most commonly performed investigation for known or suspected coronary artery disease and about 0.2–1.2% of MPS studies are associated with incidentally detected extracardiac abnormalities including parathyroid adenoma, lymphoma, lung, breast, and thyroid malignancy.[4] Pericardial effusion is rarely detected with MPS and the findings on MPS include “halo” of diminished tracer concentration surrounding the heart on projection images due to fluid accumulation as well as increased translational motion of the heart on the gated SPECT images.[5] However, echocardiography confirms the findings and allows more accurate measurements of effusion size and filling pressures during the respiratory cycle and helps in ruling out the cardiac tamponade. The finding of pericardial effusion on MPS in the index case emphasizes that projection images have been carefully reviewed before reporting on myocardial perfusion defects to identify any extracardiac abnormality with their diagnostic and prognostic implications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Austin BA, Kwon DH, Jaber WA. Pericardial effusion on Tc-99m SPECT perfusion study. J Nucl Cardiol 2008;15:e35-6.  Back to cited text no. 1
[PUBMED]    
2.
Chong HH, Plotnick GD. Pericardial effusion and tamponade: Evaluation, imaging modalities, and management. Compr Ther 1995;21:378-85.  Back to cited text no. 2
[PUBMED]    
3.
Spieth ME, Schmitz SL, Tak T. Incidental massive pericardial effusion diagnosed by myocardial perfusion imaging. Clin Med Res 2003;1:141-4.  Back to cited text no. 3
[PUBMED]    
4.
Gedik GK, Ergun EL, Asian M, Caner B. Unusual extracardiac findings detected on myocardial perfusion single photon emission computed tomography study with Tc-99m sestamibi. Clin Nucl Med 2007;32:920-6.  Back to cited text no. 4
    
5.
Herzog E, Krasnow N, DePuey G. Diagnosis of pericardial effusion and its effects on ventricular function using gated Tc-99m sestamibi perfusion SPECT. Clin Nucl Med 1998;23:361-4.  Back to cited text no. 5
[PUBMED]    


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  [Figure 1], [Figure 2], [Figure 3]



 

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