Rare association of severe iron-deficiency anaemia and moderate pericardial effusion
- 1 Cardiology, Yashoda Super Specialty Hospitals Somajiguda, Hyderabad, Telangana, India
- 2 Hematologist, Yashoda Super Specialty Hospitals Somajiguda Hyderabad, Hyderabad, Telangana, India
- 3 General Medicine, Shalini Clinic, Hyderabad, Telangana, India
- Correspondence to Dr Kartik Jadhav; drkartik303@gmail.com
Abstract
Pericardial effusion secondary to isolated severe iron-deficiency anaemia is an extremely rare condition. We present a case with severe anaemia presented with moderate pericardial effusion. Pericardial effusion completely resolved with correction of anaemia.
Background
In India, anaemia is the most frequent and readily curable health issue. According to one study, the prevalence of severe anaemia among young women of 15–20 age group is 20.5%.1 Pericardial effusion is known to occur secondary to acute myocardial infarction, cardiac surgery, trauma, neoplasia, radiation, end-stage renal disease, invasive cardiac procedures, hypothyroidism, autoimmune disease, chronic salt and water retention or acute inflammatory pericarditis.2 Pericardial effusion secondary to severe anaemia is extremely rare with only a handful of case reports published till now.3 4
Case presentation
An 18-year-old female teen presented to the outpatient department with a history of dyspnoea on exertion, progressively increasing for 3 months. Presently, she is dyspnoeic on doing her routine activity at home. Her general physical examination revealed pallor in the palpebral conjunctiva, nail bed and tongue. She also had mild pitting type of pedal oedema. She had a fast-bounding pulse of 120/min, blood pressure of 94/62 mm Hg. General examination also revealed mild pitting pedal oedema. Auscultation revealed feeble heart sounds with apical beats felt on palpation. There was no pericardial rub or murmurs. Other systemic examination showed no gross abnormality. She did reveal reduced menses discharge during menstrual cycle for 1 month. There was no history of fever, weight gain or loss, skin rashes, menorrhagia or blood loss during defecation.
Investigations
Her blood labs revealed low haemoglobin levels of 26 g/L (121–151 g/L), normal leucocyte count of 4.504×109/L (4.5–11×109/L) and normal platelet count of 540×109/L (150-450×109) /L. Her liver function tests, thyroid function test and renal function tests were within normal limits. Her anaemia evaluation showed a low reticulocyte count of 0.4% (0.5%–2.5%), low mean corpuscular volume of 72.1 fL (80–100 fL), low mean corpuscular haemoglobin concentration of 223 g/L (334–355 g/L), prothrombin time of 14.3 (control 13.6), international normalized ratio (INR) of 1.18, high serum lactate dehydrogenase of 501 IU/L (140–280 IU/L), low serum iron levels of 40 µg% (70–150 µg%), low serum ferritin of 8 ng/dL (15–150 ng/dL), high serum total iron-binding capacity of 498 µg% (280–380 µg%) and transferrin saturation of 8.03% (20%–55%). Her vitamin B12 was normal 540 pg/mL (200–900 pg/mL) and serum folic acid was normal 18 nmol/L (5–48 nmol/L). The peripheral blood film examination showed microcytic hypochromic anaemia.
The patient tested negative for hepatitis B surface antigen, human immune deficiency virus, hepatitis C virus, antinuclear antibodies and double-stranded DNA. The chest X-ray, urine routine examination, stool examination, ultrasonography of abdomen, blood cultures and blood test interferon-gamma release assay for tuberculosis were all negative. The echocardiography showed normal left ventricular and right ventricular function with normal chambers (figure 1). But there was moderate circumferential pericardial effusion with no signs of tamponade (videos 1–4).
The echocardiographic still image shows pericardial effusion at admission (A, D); 1 week after treatment (B, E) and 6 weeks after treatment (C, F).
Treatment
The patient received two units of packed red cell volume transfusion and iron deficiency was treated with intravenous ferric carboxymaltose along with diuretic use. She was discharged after 3 days of medical stabilisation on oral iron and folic acid supplementations.
Outcome and follow-up
Repeat echocardiography showed mild pericardial effusion. Review after 6 weeks showed haemoglobin level of 102 g/L and normal iron studies (table 1). Echocardiography revealed complete resolution of pericardial effusion with completely normal echo findings. There was resolution of dyspnoea and patient was completely symptom free.
Table showing post-treatment improvement in haemoglobin level
| Day | Blood haemoglobin level in g/L | Mean corpuscular volume in fL | Pericardial effusion on echocardiography |
| At admission | 26 | 72 | Moderate |
| Day 3 postadmission | 61 | 81 | Moderate |
| Day 9 | 82 | 84 | Mild |
| Day 48 | 102 | 86 | None |
Discussion
Iron-deficiency anaemia is most common form of nutritional deficiency throughout the world. Severe iron-deficiency anaemia has lethal effect on heart. The effects include left ventricular dysfunction, high output failure, pulmonary oedema, congestive heart failure and can lead to cardiomyopathy.5 Pericardial effusion is rarely described as consequence of severe anaemia. A case series of two cases published way back in 1950, described two females of age 19 and 74, respectively. Both suffered from severe anaemia and presented with large pericardial effusion requiring tapping. Both patients suffered from pernicious anaemia.3 Only other case series of two patients is from India where both the cases suffered from iron deficiency anaemia. Two females, aged 20 and 58 years, were featured in this case series by Lakhotia et al.4 Both of them presented with dyspnoea on exertion and pedal oedema. Exertional dyspnoea and pedal oedema were also found in our patient. When the anaemia was treated medically, the pericardial effusion and pedal oedema disappeared promptly. As a result, severe anaemia could be the cause of the pericardial effusion. All the common causes for pericardial effusion such as hypoproteinaemia, nephrotic syndrome, hepatic failure, pregnancy, hypothyroidism for transudative effusion and infectious pericarditis, inflammatory pericarditis for exudative effusion were ruled out in our case. We did not perform a pericardial tapping as there was no sign of pericardial tamponade.
Reduced inhibition of baseline endothelium-derived relaxing factor activity results in widespread vasodilation when haemoglobin levels are low. This vasodilation leads to oedema and transudative effusion.6 The oedema and effusion of various body cavities like pleural and peritoneal cavities are known to happen commonly. But pericardial effusion in severe anaemia is not commonly known to happen and is a rare association. Due to increased vascular pressure in blood vessels and negative intrapleural pressure of −6 mm Hg, transudative fluid accumulation is common in anaemia.7 The intrapericardial pressure (0–1 mm Hg) is higher than intrapleural pressure (−3 to −6 mm Hg), therefore, transudative effusions appear commonly in pleura than pericardium.8 But here the case has pericardial effusion with no pleural effusion, which is quite rare. The possible mechanism could be due to cuboidal mesothelial cell dysfunction (enclosing milky spots on parietal pericardium) secondary to anaemia, which acts like an access to lymphatic system draining fluid and cells from intra-pericardial space. This loss of function may cause accumulation of pericardial fluid over a period of time and cause effusion to occur.9
This particular case is extremely rare and has been scarcely reported. Therefore, this case should help us understand mechanism and rare presentation of severe anaemia.
Patient’s perspective
1 weeks before
I started experiencing breathing difficulty and went to a local physician. He advised me to get few blood tests done. Because we had to travel to a different city for the tests to be performed, therefore I continued with the medications for the time being.
1 day before
The medications failed to resolve my symptoms, therefore we decided to travel to the city for further management.
Day 0 at admission
During the OPD consultation, multiple tests were done. Then doctor explained to me that there is low blood levels and there is water accumulation around the heart. Therefore, I got admitted. I was given multiple injections including a bag of blood. With these injections I felt much better, my breathlessness reduced.
Day 1
I was again given another bag of blood and injections were continued.
Day 2 and 3
At the end of 3 days, I was told that as the symptoms improved there is no need to remove water around the heart. I was discharged and told to review later.
Day 9
During review, repeat heart scan showed some small reduction in water around heart. I was told to continue the same medications.
Day 48
During second review another repeat scan showed no water accumulation around the heart. My blood levels too increased. I was told to continue the medications.
Learning points
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Pericardial effusion secondary to severe anaemia is an extremely rare association.
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All of the cases reported so far have been women.
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The symptoms of dyspnoea and pericardial effusion on echocardiography resolved immediately after treatment of anaemia.
Ethics statements
Patient consent for publication
Acknowledgments
Dr Kashyap Vyas, Resident in Cardiology, Yashoda Hospital, Somajiguda, Hyderabad, India. Mr Anvesh, Public Relation Executive (PRE), Yashoda Hospital, Somajiguda, Hyderabad. Sujata, Echocardiography technician, Yashoda Hospital, Somajiguda, Hyderabad, India.
Footnotes
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Twitter @pankajanusha
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Contributors All the four authors have made substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; KJ, PJ and GJ were involved in drafting the work and PV helped in revising it critically for important intellectual content; Final approval of the version to be published were done by all the authors. All the four authors are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Signed by PJ, KJ, GJ and PV.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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