UNEXPECTED LYMPHOMA IN AN EXPECTANT WOMAN REVEALED BY CARDIAC TAMPONADE.

Amal. ELAissaoui, K. Bentahar, Y. Ouharakat, I. Asfalou and E.Zbir. Cardiology center of Instruction military hospital Med V of RABAT. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 08 April 2019 Final Accepted: 10 May 2019 Published: June 2019

patient was initially resuscitated with intravenous fluids and inotropic agents. -Blind‖ pericardial aspiration was initially performed with unsuccessful clinical result. Wheras Pericardial aspiration under transthoracic echocardiographic guidance was required, with removal of a total of 1500 ml of citrine yellow liquid, over 3 days. afterwords repeat echocardiogram demonstrates no reaccumulation of fluid, the pigtail catheter was removed from the pericardial cavity.
MRI (Magnetic Resonance Imaging) performed later, shows Anterior mediastinal huge mass, with several connections ( pulmonary parenchyma, aorta, digestive axis ) accessible for biopsy. This later combined with anatomopathological study demonstrated a morphological and immunohistochemical profile of Primary mediastinal large B-cell lymphoma associated with delicate interstitial fibrosis.patient was referred to a hematology department for management. Spectacular improvement of clinical signs was obtained after a first line chemotherapy including rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Fetal echography has showed no evidence of structural or functional diseases on the fetus.The baby had not shown any developmental delays or physical abnormalities.   On the other side Insidious pericardial effusion of small abundance occurs in almost 40% of pregnant women during their third trimester of pregnancy.It is mainly due to viral or autoimmune disease;rarely do we find a neoplastic etiology. However,Inaugural presentation or evolution in cardiac tamponade is even rarer or even exceptional [5,6,7] Mediastinal lymphoma may produce a pericardial effusion, but rarely presents as cardiac tamponade [7]. The association of all those conditions: pregnancy, lymphoma, in a cardiac tamponade context, made all the authenticity of this case.
In fact, Cardiac tamponade is a medical emergency condition which classical clinical presentation is an elevated venous pressure, decreased systemic arterial pressure and a quiet heart as described in Beck's paper,long time ago. [8] However, although in another study of 56 patients it has been shown that this triad is often incomplete. The major symptoms are dyspnoeato breathlessness. Physician found tachypnoea, tachycardia, pericardial rub and pulsusparadoxus. [9] ECG might show sinus tachycardia, low voltage complexes and non-specific ST segment and T wave changes due to pericarditis. Pendular swinging motion of the heart within a pericardial effusion is manifested by Electrical alternance and it is characteristically seen only with a large effusion. [11] The ECG must be used to rule out other aetiology of hypotension rather than confirm the diagnosis of cardiac tamponade. [9].
Echocardiography is the tamponade first line of diagnosis for the positive and severity diagnosis; it can also allow the diagnosis before the installation of clinical sign [12]. It quantifies liquid effusion and appreciates the signs of tolerance. It can be detected initially by an abnormal septal motion, right atrial and right ventricular diastolic collapse, and reduced respiratory variation of the diameter of the inferior vena cava; TTE can also assess the distribution of the effusion [9] Echocardiographic allow also guidance of pericardiocentesis .This later is the technique of catheter-based aspiration of pericardial fluid. It serves as a diagnostic modality via fluid analysis and a therapeutic modality especially with hemodynamic compromise [3], such as our patient case.
After acute management of this emergency, establishing An etiologic diagnosis can be a major dilemma especially in a pregnancy condition where Neoplastic pericarditisis is not common. Thuspericardial fluid cytology and pericardial/epicardial biopsy findings, CT/MRI, Increased concentrations of specific tumour markers could assess diagnosis.
The management of PMBCL involves chemotherapy and radiation. In pregnancy, therapeutic is a real dilemma, since we had limited knowledge about risks who vary with the treatment used and the term of the pregnancy of cytotoxic treatments for fetal development and on the future development during childhood. In our case, we adopt an R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen who achieve a cure rate of 82% in literature [13,14].
In fact, this therapy allowed a spectacular improvement of clinical signs. The patient had received the entire chemotherapy during her pregnancy with a regular multidisciplinary follow up. Delivery was uneventful.

Conclusion:-
Cardiac tamponade is a life-threatening emergency; mortality might be higher in pregnancy, requiring immediate pericardiocentesis. Neoplastic etiology is not common. We highlights in this case that PMBCL can exposes to cardiac tamponade, that Pericardiocentesisis is the first line therapy and the fact that managing pregnant patients with hematological tumors pose more conflicts.
Since A multidisciplinary approach, including oncologists, radiologists, obstetricians, cardiologist and psychiatrist specialists, social services, is mandatory to optimize management