| Infectious Diseases / Cardiology |
1. Disseminated Cyrptococcosis in a Patient with HIV Infection PP Prasad*, R Prahlad**, P Ramulu***, R Siddeshwari***,
B Sudarsi+, M Arun++ A 40 year old male patient presented with history of fever,
cough and rash all over the body of one month duration. Fever
was of low grade and intermittent in nature. Cough was
productive with minimal while coloured sputum. Rash started
as small popular lesions over the face and upper torso which
later became generalized and increased in size leading to rupture.
Rash occurred in crops ever 3-4 days. Patient had history of
diabetes and high risk sexual behaviour. His wife was recently
diagnosed with pulmonary tuberculosis and was on treatment. Conclusion : Middle aged male presenting with disseminated cryptococcal infection secondary to HIV infection. 2. Correlation of CD4 Counts with Pulmonary and Extrapulmonary Tuberculosis in 150 Consecutive Cass of HIV/AIDS AD Mathur, D Bhattacharyya, CS Narayanan, SP Singh,
VK Gupta, JS Bishnoi, SK Datta, MS Sandhu, R Pakhetra Object of the Study : To study the correlation of CD4 counts
with pulmonary and extra-pulmonary tuberculosis in 150
consecutive HIV patients in a service hospital.
Methodology : Patients reporting to a tertiary care service Conclusion : HIV/AIDS patients with high CD4 counts (more than 200 cells/μL) has higher incidence of pulmonary tuberculosis, whereas in patients with low CD4 counts (200 cells/μL) incidence of extra-pulmonary tuberculosis is high. All patients with HIVTB responded well to ART and ATT. Hence these drugs should be started at the earliest in a case of HIV-TB. 3. A Case Series of Cryptococcal Lymphadenitis V Thyagaraj, U Devaraj, B Mathew, S Jose Prior to the AIDS epidemic, Cryptococcosis occurred sporadically in both man and animals throughout the world. Littman and Zimmerman counted 300 cases in the world medical literature upto 1955, but the reports of lab confirmed cases have sharply increased since aggressive immunosuppressive therapy came into wide use. Cryptococcosis is the 4th most commonly recognized cause of life threatening infection among AIDS patients and is the presenting manifestation of AIDS in about a third of these patients. Cryptococcal infection commonly manifests as meningioencephalitis (60%), pneumonia (20-30%), skin lesions 910%), bone and joint involvement (5%) and eye lesions. Rare manifestations include lymphadenopathy, endocarditis, hepatitis, lesions of GI tract, pyelonephritis and prostatitis. We report 3 cases of cryptococcal lymphadenitis in HIV infected patients. In one, lymphadenopathy was the presenting feature. All had advanced HIV infection, and diagnosis was confirmed by histopathological examination. One patient succumbed to cryptococcal meningitis. Cryptococcal lymphadenitis has been reported in literature as a rare manifestation. 4. Fever of Undetermined Origin in Patients Infected with HIV : Report on 69 Cases PA Krishna, MVS Subbalakshmi, M Shetty, T Manmadharao,
VR Srinivasan Aim : Spectrum of clinical diseases diagnosed in HIV patients presented with FUO. Methods : Case records of 69 HIV-infected patients who came with a chief complaint of prolonged fever (fever > 100oF for alt least 2 weeks), over last 6 ½ years, were restrospectively analyzed. Retroviral status was confirmed in all by Western Blot and CD4 cell count. Results : Age range was 19 to 68 years with mean 35 years. Males were 56 and females 13. CD4 in 68 patients were < 500 cells. Duration of fever varied from 3 weeks to 1 year. Loss of appetite and weight was noted in 33 patients. On examination hepatomegaly was noted in 18, splenomegaly in 13 and lymphadenopathy in 32. Radiograph of chest showed abnormality in 21 cases (pleural effusion – 8; hilar lymphadenopathy – 6; para-tracheal lymphadenopathy-2; parenchymal infiltrates-5; consolidation-4; atelectesis-1; miliary motting-1 and upper lobe cavity and fibrosis- 1). Ultra sonogram of abdomen revealed clue in 32 cases. (abdominal lymphadenopathy-22; ascites-7; hepatomegaly-14; spleenomegaly-12; splenic SOL-7; liver SOL-3; bowel thickening- 1 and pericardial effusion-1). CECT of chest provided clue in 2 cases where chest radiograph is normal (mediastinal lymphadenopathy-2, miliary infiltrates-1). MRI of brain was abnormal in 1 case. Definitive diagnosis was reached in 21 patients. It was achieved by sputum test in 6 patients (Koch’s-4, Klebsiella-1 and PCP-1); by blood culture in 2 (Cryptococci-1 and Klebsiella-1); by urine culture in 2 (E. coli-2); by FNAC or biopsy of lymph node in 21 (Koch’s-18; Cryptococci-1 and NHL-2); by bone marrow study in 4 (Koch’s-1, cryptococci-1 and NHL-2). A clinical diagnosis was made in 30 patients (Koch’s-22, PCP-2 or septicemia-5), basing on the clinical profile and treated accordingly. No cause was found other than HIV infection in the rest 7 patients. Conclusions : 1. Infections remain the most important cause of FUO in HIV patients. 2. Tuberculosis (especially extrapulmonary) is the commonest cause. 3. Non-infectious causes were in minority in this series. 4. In situations where evaluation does not reveal a cause for prolonged fever, anti-tuberculous trail therapy in selected patients may be justified. 5. Clinical Spectrum of Pulmonary Complications in HIV Status R Mittal, PM Upasi, KP Sajith Background and Objectives : Respiratory infection in immunocompromised host has become a major clinical issue with the advance of HIV infection. About 70% of HIV infected individuals have one respiratory episode during the course of their disease. The aim of the study is to explore the spectrum of pulmonary complications in HIV seropositive individuals. It also helps in early intervention which will bring better outcome. Methods : The study was done over a period of 20 months in 50 HIV seropositive individuals with associated pulmonary complications. Results : Among 50 patients, tuberculosis was found in 30
patients (60%). Acute bronchitis (18%), Bacterial pneumonia
(12%), and Pneumocystis carinii pneumonia (10%) follows the
suit. Extrapulmonary tuberculosis was found in 43.33% of TB
cases with lymphnode (6 patients) being the most common site
of involvement. Sputum AFB was found to be positive only in
33.33% of TB cases, while culture was positive in 66.67% of
cases. In all cases of PCP and Bacterial pneumonia, CD4 counts
were found to be < 200 cells/mm3.
Interpretation andConclusion : Tuberculosis was found to be
the most frequent pulmonary complicating among HIV
seropositive individuals. Sputum AFB positivity was found to
be very less in patients with dual infection of TB and HIV. The 6. Abdominal Tuberculosis, Our Experience from 50 cases in The North-East S Banik, AK Adhikari, N Goswami S Baruah, H Kalita,
C Modak Aim : To emphasize the importance of Ultrasound and US guided Lymph node FNAC/Ascitic fluid analysis as a major tool for diagnosis of abdominal tuberculosis. Methods : 50 patients with clinical features suggestive of abdominal TB (fever, weight loss, altered bowel habits, abd distension or lump) are evaluated and investigated by ultrasound and diagnosis confirmed by US guided ascetic fluid analysis (22 pts, 44%), US guided FNAC of abdominal nodes (19 pts, 38%) and response to therapy (9 pts, 18%). Results : Ascites was detected in 70% cases. Other common findings were intra-abdominal lymphadenopathy (65%), thickened bowel loops (33%), presence of septations, dilated and matted bowel loops in the peritoneal cavity (25%), 10 (20%) pts had past H/O pulmonary TB. Conclusions : In proper clinical setting, US examination is a very essential step in the diagnostic work-up for Abdominal TB. Combination of ascetic fluid analysis, FNAC of abdominal nodes and US findings together can provide a good diagnostic yield in more than 83% cases. 7. A Case of Oesophageal Tuberculosis in AIDS BS Thongam, S Bhagyabati Devi, N Biplab Singh,
Th. Suraj Singh, Ph. Rabindro Singh A 56 yrs. old homosexual male presented with odynophagia and painful defaecation. He was found to be retro reactive, CD4 count 196/mm3, anorectal candidiasis and a large malignant looking ulcer at lower end of oesopahgus. The oesophageal ulcer was diagnosed as tubercular by endoscopic biopsy and mycodot. It got healed after two months antitubercular treatment without antiretroviral treatment as evidenced by endoscopy and raised CD4 count 216/mm3. Tuberculosis at the lower end of oesophagus as extrapulmonary tubercular manifestation in AIDS is reported probably for the first time Homosexual is also becoming one of the important routes of transmission of AIDS and ATT to be started first when HIV-TB Co-infection is there. 8. A Rare Case of An Acute Transverse Myelitis Following Chikungunya Infection KR Shah Introduction : A transient myelopathy may develop within weeks of viral infection. It is thought to be due to transient demyelination of the posterior columns of the spinal cord. No intravention is required in most cases. The syndrome usually resolves spontaneously after several weeks. Aim : Rare presentation as acute tranverse myelitis following chikungunya infection. Case : A 58 year old male patient presented to us on 30/9/06
with history of high grade fever of 3 days duration, severe
incapacitating joint pain (knee, ankle, elbow, wrist and small
joints of hands) and rashes all over body of recent onset. On
examination his vital signs were stable. Temp – 100oF, Pulse-
104/min, BP-136/90 mm of Hg, maculopapular rash all over body, tender joints. He had retention of urine. Provisional diagnosis
of viral fever i.e. Chikungunya was established in view of ongoing
epidemic. With conservative treatment (Paracetamol, Piroxicam,
IV fluids and catheterization) fever, joint pain and rash subsided
but he developed paraplegia. Examination revealed severe
symmetrical paraparesis (power grade I-II) with flaccidity, absent
reflexes and extensor plantar responses. There was minimal
sensory impairment below D6, CT Scan head and MRI Lower
dorsal spine were normal. Routine CSF examination showed
normal, clear, colorless fluid and protein-42 mg/dl, sugar-58
mg/dl (MBS-104 mg%), microscopic examination showed 30
total cell count (all lymphocytes). Further investigation revealed
presence of IgM antibodies against antigens of Chikungunya virus 9. Study of Hospital Acquired Pneumonia in A Tertiary Care Centre R Girish, R Bhat Introduction : Hospital Acquired Pneumonia (HAP) is the second most common nosocomial infection, accounting for up to 30% of all nosocomial infections; it carried the highest morbidity and mortality. Assessing the risk factors and organisms involved and their resistance patterns to antibiotics will help to better intervention measures. Aims and Objectives : 1. To study the risk factor involved in HAP. 2. To assess the significance of colonization of the respiratory tract in HAP. 3. To identify the microbiological cause of HAP. 4. To identify resistance pattern of organisms causing HAP. Material and Methods : This is a prospective study being undertaken in Kasturba Hospital, Manipal a tertiary care referral centre. The criteria used for diagnosis of with HAP was based upon American Thoracic Society guidelines. Observations : 25 patients were studied from November 2006 till now. Of all the risk factors that were studied Diabetes (60%), Cerebrovascular accidents (36%) were the commonest. Aspiration pneumonia (40%) and ventilatory associated pneumonia (VAP) (60%) were the commonest cause of HAP. The commonest organism isolated were Acinetobacter and Pseudomonas species. Conclusions : 1. Ventilatar associated pneumonias were the most common cause of HAP and they were associated with high mortality. 2. Immunocompromised and altered sensorium were the most common risk factors involved. 3. Multidrug resistant Pseudomonas and Acinetobacter were the commonest organisms isolated. This study is still going on and the final conclusions will be presented in the conference. 10. Antiretroviral Therapy and It’s Outcome MM Paithankar/SD Kaur, R Khot This study was conducted at ART Clinic Government Medical College, Nagpur with the objective of studying the outcome of HIV/AIDS patients on Antiretroviral therapy. Total 200 patients were included in the study and were put on generic fixed dose combination of Nevirapine (200 mg bd), stavudine (30 mg bd) and Lamivudine (150 mg bd) and followed up for a period of 6 months. These patients were also put on drugs for opportunistic infections along with ART. After 6 months of ART there was significant rise in CD4 count and Karnofsky score in both males and females (P = 0.000). 78.13% of males and 78.72% of females had significant gain in weight, 64.58% of males and 55.32% of females had significant rise in Hb%, 92.7% of males and 93.62% of females had significant rise in ALC. Only 11.5% patients developed toxicity to ART in the form of neuropathy (6%), rash (4.5%) and hepatitis (1%). Mortality was only in 9.5% of patients, all were males and were in stage IV. Thus, it was concluded that this generic fixed dose combination of Nevirapine, Stavudine and Lamivudine decreases the morbidity among patients and thus, prolong their life. 11. Pulmonary Tuberculosis and Median CD4 Count in PLWHAs RS Venkatesh, RA Kumar, VK Rajamani,
P Thirumalikolundusubramaniam Objectives : Pulmonary Tuberculosis is the commonest opportunistic infection among PLWHAs (People living with HIV/ AIDS) in India. The aim of our study is to analyze the incidence of Pulmonary tuberculosis and the mean CD4 count among PLWHAs. Methods : 1159 newly diagnosed patients with HIV infection in 2005-2006 attending our institute were screened for Pulmonary tuberculosis with sputum examination and chest x-ray. Flow Cytometry was used to determine the CD4 count. Results : 1. In 2005 the incidence of Pulmonary Tuberculosis was 14% and the median CD4 count was 112 cells/cu.mm at the time of diagnosis. 2. In 2006 the incidence of Pulmonary Tuberculosis was (10.7%) and the median CD4 count was 87 cells/cu.mm at the time of presentation. Conclusion : At the time of diagnosis 13% of the PLWHAs have Pulmonary Tuberculosis and the median CD4 count was 100 cells/cu.mm which is in contrast to the Western Countries where the median CD4 count is 326 cells/cu.mm. 12. Clinical Study of Severe Leptospirosis with Special Reference to Serum Amylase and Lipase Levels MP Maukhyaprana, KS Nataraj, R Balasubramnian Introduction : Leptospirosis is zoonatic disease common in coastal area. In severe leptospirosis renal failure, hepatic dysfunction and thrombocytopenia are common. Severe pain abdomen with elevated pancreatic enzymes with pancreatitis like picture is rarely described in leptospirosis. Aims and Objectives : 1. To analyze clinical presentation, typical and atypical manifestations of severe leptospirosis. 2. To assess whether serum amaylase and serum lipase correlated with severity of leptospirosis. Study period and setting : 1st May 2006 to 31st Dec. 2006, KMC Hospital, Manipal. Material and Methods : All leptospirosis patients diagnosed based on IgM positivity were analyzed with respect to clinical presentation and lab parameters (Blood counts, renal function Liver function tests). Serum amylase and lipase were estimated in all cases with ultrasound abdomen/CT scan abdomen was done in relevant cases with respect to suspicion of pancreatitis. Observations and Results : 24 patients were admitted with severe leptospirosis. 3 patients expired. Fever was presenting complaint in all cases, whereas pain abdomen was seen in 50% of cases. Renal failure was seen 92% cases whereas hepatic dysfunction with hyperbilurubinemia was seen in 75% cases. Amylase and lipase levels were elevated in 21 and 18 patients respectively. 2 patients had pancreatitis changes in ultrasound with elevated enzymes consistent with diagnosis of acute pancreatitis. All patients with elevated amylase and lipase had acute renal failure whereas 1 patient with elevated amylase and lipse had ARDS. Pancreas was normal in ultrasound in 16 patients with elevated enzymes and was not visualized in 4 cases. Conclusions : 1. Multiorgan involvement including pancreas in not uncommon in severe leptospirosis. 2. Pancreatitis in leptospirosis may be part of severe disease. 3. Raised amylase in leptospirosis may be multifactorial, may not be pancreatic involvement in all cases elevated lipase levels might correlate with the severity. 13. A Case of Pulmonic Stenosis with Infective Endocarditis R Tolstoy, T Saravanan, K Jayachandran, G Rajendran 45 yr. old male, deaf and mute by birth – admitted on 6:3:2006 for low grade, intermittent fever, with chills and rigors – 1 week duration. Also had retrosternal chest pain, burning sensation – no radiation, no relation to respiration. Clinically, found to have pectus excavatum, tachypnoea, sweating, JVP elevated (prominent a wave). BP 110/80 mm Hg. PR 88/min. prominent, epigastic pulsation, Grade IV ESM in pulmonary area with soft P2. P/A hepatosplenomegaly (mild) present. Clinically, valvular pulmonic stenosis with infective endocardits was thought of ECGwise RVH, CRBBB. Echo (TTE) was done – severe pulmonic stenosis – moderate Pericardial Effusion – vegetation on PV with RV dysfunction, (PS gradient 58 mmHg) which was confirmed by TE. 3 samples of blood C/S – negative. With 6 weeks of antibiotic (Inj. Ampicillin and Inj. Gentamicin) therapy, patient afebrile, Echo showed clearance of vegetation. This case is presented for the rare incidence of IE in congenital pulmonic stenosis. 14. A Study of Plasma NT-PRO BNP and Troponin-I in Detection of Anthracycline Induced Cardiotoxicity A Pradhan*, S Mehrotra, M Chandra
*Junior Resident Aim : To study the role of plasma NT-PRO BNP and Trophonin- I in detection of anthracycline induced cardiotoxicity and study the effect of cumulative dose. Method : A point study comprising of serum plasma NT-PRO BNP and Trophonin-I and 2D echocardiography in patients who have undergone anthracycline chemotherapy preferably three months after completion of chemotherapy. Result : Preliminary results showed that only 33% of patients with asymptomatic LV diastolic dysfunction on 2D echocardiography had elevated plasma NT-PRO BNP or Trophonin-I levels. Full results will be available by APICON- 2008. 15. A Study of Plasma NT-PRO BNP in Rheumatic Mitral Valve Disease R Sanguri*, M Chandra, A Chandra, AK Vaish, S Mehrotra Aim : To evaluate plasma NT Pro BNP levels in Rheumatic mitral valve disease and correlate plasma NT ProBNP levels with Echocardiographic findings in patients Rheumatic mitral valve disease. Method : Our study group will contain patient with rheumatic mitral valve disease (moderate to severe mitral regurgitation with left ventricular dysfunction excluded). In this study group we will correlate plasma NT-ProBNP levels with clinical symptoms and echocardiographic findings such as cross sectional area of mitral value, LA size, transvalvular gradient and pulmonary artery hypertension. Result : Preliminary results showed that the serum levels of NTProBNP correlated best with pulmonary artery pressure. 16. Limitation of Angina Scoring System in Presence of Gastroesophageal Reflux Disease R Dewan, S Tyagi, S Debbarma, RB Thandessary, N Relia,
S Bhattacharya, R Khullar Introduction : Gastroesophageal reflux disease (GERD) is very common in coronary artery disease (CAD) patients and can cause pain chest indistinguishable from angina, especially when it is known that exercise can induce gastroesophageal reflux (GER). The present study investigates the effect of proton pump inhibitors (PPIs) on Canadian Cardiovascular Society Classification (CCSC) of Angina scores in patients with coexisting GERD and CAD. Material and Methods : 30 CAD patients who were treadmill test positive with GERD were investigated. Their angina grade was assessed by CCSC followed by simultaneous 24 hours pH metry and Holter monitoring. All the patients then received 1- month course of omeprazole (proton pump inhibitor). Their angina grading, pH metry and Holter study were angina repeated. Results : Of 30 patients 6 (20%) were of angina 1, 20 (66.7%) were of grade 2 and 4 (13.3%) were of grade 3. On pH metry, 427.33 pathological refluxes were recorded in distal probe and in proximal probe 143 were recorded. A total of 406 chest pain episodes ranging from 4-25 in number were reported. Of these 317 were associated with pathological refluxes, 49 with electrocardiogram (ECG) changes and 40 were not associated with either 1 month course of omeprazole showed a significant reduction in number of chest pain episodes to 44 and pathological refluxes to 123 (p < 0.001). The angina score of these patients also improved significantly with 23/30 (76.7%) of grade 1, 6/30 (20%) of grade 2 and 1/30 (3.3%) of grade 3 (P < 0.001). Conclusion : A course of proton pump inhibitors is recommended before grading angina in patients of coronary artery disease with coexisting gastroesophageal reflux disease. 17. Serum C-Reactive Protein Concentration in Acute MI and Its Relationship to Complications and Mortality G Mohan, N Bhalla, M Arora, M Chandey Introduction : The commonest cause of Acute MI is considered to be plaque rupture which causes release of many acute phase reactants. Myocardial necrosis also causes release of various acute phase reactants like C-RP CRP is marker of atherosclerotic inflammation and myocardial necrosis. Aim and Objective : To study the relationship between serum C-RP concentration and complication / mortality in acute MI. Material and Methods : In the present study 50 AMI patients selected for thrombolytic therapy of either sex were included. Diagnosis of AMI was based upon history clinical exam. 12 lead surface ECG changes and increase in levels of cardiac enzymes. 50 healthy age and sex matched individuals were taken as control. Non cardiac causes which can raise CRP were excluded from both groups. Blood samples of AMI patients for CRP was sent at the time of hospital admission and repeated twice. Other cardiac markers like CPK MB and trop – I were also estimated to correlate with CRP levels. Patients were followed up for 6 months for complications MI and mortality. The highest serum concentrations of C-RP were correlated to total mortality as well as to the causes of death 3, 3-6, 6-12, 12-24 week after the onset of MI. Results :
Conclusion : High serum CRP concentration in AMI patients predict increased complications and mortality (in hospital) and upto 6 months following the infarction. Accordingly reduction of inflammatory reaction by successful thrombolytic therapy may make an important contribution to the survival benefit to thrombolytic therapy in Acute MI. 18. Effect of Atrovastatin with Ezetimibe vs Atorvastatin Alone on Lipid Profile in Patients of CAD Rao Harbir Kaur, K Kaur, GK Bedi, BL Bhardwaj, RS Gupta,
AR Singh, M Arora There still remains a distinct gap in the therapy of Hyper Cholesterolaemia with statins alone. This gap is being bridged by Ezetimibe. Ezetimibe is a selective cholesterol absorption inhibitor whose clinical efficacy has been recently demonstrated. The present study was conducted on 100 cases of CAD which fulfilled the diagnostic criteria. After through physical examination and investigations including Lipidogram, the case were randomly divided into age and sex matched two groups of 50 cases each. Group I cases were administered Atorvastatin 10 mg daily along with other drugs whereas Group II cases were given Atorvastatin 10 mg and Ezetimibe 10 mg. Lipid profile was repeated after 12 weeks and also at the end of 24 weeks. Atorvastatin 10 mg/day in Group I reduced Total Cholesterol (32.87%), Triglycerides (24.85%), LDL-Cholesterol (44.09%), Total Lipids (25.72%) and increased HDL by 4.9% after 24 weeks of therapy. On the other hand, Ezetimibe 10 mg/day + Atorvastatin 10 mg/day in Group II reduced Total Cholesterol (41.29%), Triglycerides (34.55%), LDL-Cholesterol (54.33%), Total Lipids (30.85%) and increased HDL by 7.9% after 24 weeks. Maximum improvement in Lipid Profile was achieved during the 1st 12 weeks and change was maximum with Atorvastatin + Ezetimibe as compared to Atorvastatin alone! 19. Clinical and Echo Profile of Pericardial Effusion in The Present ERA UK Narasimhul, TN Kumar, Nitinkabra, AD Kumar, S Reddy Objective : The aim of the study in detail, the clinical presentation of patients with pericardial effusion with special emphasis on Aetiology. Methods : During the period of October 2004 to April 2007 in Gandhi Hospital/Gandhi Medical College, Secunderabad – 123 pericardial effusion cases were studied in detail emphasizing on clinical presentation in correlation with 2D Echo Cardiography and Aetiology. Results : Clinical Presentation : Pulsus paradoxus : 11%, Raised JVP : 99%, Kussmaul’s sign : Present in two cases of pericardial effusion with thickened pericardium. Muffled heart sounds in 50%, pericardial knock in 3 cases, pericardial rub in 2 cases, Hepatomegaly in 60% cases were observed. Investigation : ECG of low voltage complexes noted in 48%, CXR – Cardiomegaly in all cases were noted, pericardial effusion associated with pleural effusion noted in 5 cases (right sided – 2; left sided – 2; bilateral – 1). Other investigations like bio-chemical analysis of the fluid, PCR, 2D Echo done. Massive pericardial effusion – 24 (19.5%), and with pericardial tamponade – 15 (12%), moderate – 35 (28%). Aetiology – Tuberculosis – 55 (48%), Cardiomyopathy – 19 (27%), Post MI – 18 (15%), Valvular (CHRD) – 6, Hypothyroidism – 9 (7%), Pyogenic – 3 (2.5%), Amoebic – 1, Congenital – 2, Connective Tissue disorders – 4, Viral (AIDS) – 5, Post Surgery – 1, Trauma – 1. Conclusion : No single approach should be used to diagnose all cases of pericardial effusion. The diagnosis may be made on the basis of history, physical examination and chest radiography. In other patients, echo-cardiography may be required. The most important diagnostic tool is the clinical suspicion of Pericardial Effusion. |