TOPIC: Signs and Symptoms of Chest Diseases
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Pericardial effusions are caused by numerous etiologies including metabolic, cardiac disease, infection, neoplastic, or idiopathic. They may be isolated or part of a systemic illness. Severe iron deficiency anemia causing pericardial effusion has been rarely reported and is not well studied1.
      CASE PRESENTATION: A 48-year-old female without significant past medical history presented with shortness of breath and exercise intolerance. She reported a five-month history of menometrorrhagia with blood clots. Physical examination was significant for a grade 3 systolic murmur and pitting edema to the knees. Labs revealed a hemoglobin of 1.7 g/dL, hematocrit of 6.3%, MCV of 51, RDW of 34.2, and reticulocyte count of 0.0245. Hemolysis markers were negative. She was transfused four units of packed red blood cells. Iron studies were not collected prior to administration of the blood transfusions, and therefore, iron studies were not available for review. However, peripheral smear demonstrated hypochromic and microcytic red blood cells with anisocytosis, poikilocytosis, and cigar cells which are diagnostic of iron deficiency anemia. She received 1 g IV Dextran for her presumed iron deficiency anemia. Echocardiogram revealed a moderate-large circumferential pericardial effusion anterior and posterior to the heart without evidence of tamponade. The location of the effusion and her anemia precluded pericardiocentesis. Other rheumatologic and cardiac workup was negative. Her symptoms improved and she was transitioned to oral iron supplementation with a hemoglobin at discharge of 6.6 g/dL.Within three weeks of iron infusion, her hemoglobin normalized to 12.3 g/dL. A repeat echocardiogram three months after her presentation showed a small posterior pericardial effusion, markedly reduced from prior. During this period, she was readmitted for new onset status epilepticus, thought to be due to CNS vasculitis.
      DISCUSSION: In this patient, her subsequent hospitalization for seizures was highly suspicious for CNS vasculitis based on her imaging, presentation, and overall response to steroids. Brain biopsy however was negative for vasculitis. While it is possible that her pericardial effusion was related to an underlying autoimmune disorder, her initial rheumatologic work up was negative, and her pericardial effusions did resolve with treatment of her iron deficiency anemia. Iron deficiency anemia is an unlikely cause for pericardial effusion, and overall literature remains sparse with only two case reports documented2.
      CONCLUSIONS: Iron deficiency anemia has been associated with high output heart failure, and subsequent pulmonary arterial hypertension, which may cause pericardial effusions3. The differential diagnosis for pericardial effusion is extensive and should be considered in each clinical context with every patient.
      REFERENCE #1: Adler Y, Charron P, Imazio M, Badano L, Baron-Esqivias G, Bogaert J, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). European Heart Journal 2015;36(42):2921-2964.
      REFERENCE #2: Lakhotia M, Singh J, Pahadia H, Kumar H, Sanghvi S. Pericardial effusion in severe iron deficiency anemia. Heart India 2014;2(3):88-90.
      REFERENCE #3: Rhodes CJ, Wharton J, Howard L, Gibbs JSR, Vonk-Noordegraaf AV, Wilkins MR. Iron deficiency in pulmonary arterial hypertension: a potential therapeutic target. European Respiratory Journal 2011;38(6):1453-1460.
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