EWART’S SIGN A CLINICO-RADIOLOGICAL REVIEW.

Objectives: To report a case of pericardial effusion which present the clinical and radiological basis for Ewart’s sign. Case: We present an 86 years old female who is known to suffer from Type II diabetes mellitus on Insulin mixtard, she also takes Perindopril 5 mg for hypertension. She presented with one-month history of breathlessness and cough associated with night sweats. No past medical history of f TB or contact with TB. When examined in the ER she was found tachypnic (RR22) with pulse rate 85, small volume and BP 130/80 (non pulsus paradoxus) and saturation of 92% in room air. Her chest examination showed: dullness left base posteriorly below the left scapula with Bronchial breathing (Ewart Sign). Examination of Cardiovascular System reviled muffled heart sound JVP raised. No Lymph nodes were felt and her abdominal examination was unremarkable. TST: no reaction to 2TU PPD (Mantoux test). Bloods including TSH and autoimmune screen: TSH Normal, Urea 9.7 with Normal Creatinine and normal liver function test, CBC: WBC 8.1 Hb 12.7 and Platelets 215. ESR 61. Echo: massive pericardial effusion EF 50%RVSP 45 and thickened pericardium. Echo free space 2.5 cm posterior and lateral .RV diastolic collapse. ECG showed small voltage QRS complexes with no acute ischemic changes. CXR (Fig 1&2) showed increased cardiac shadow. CT chest with contrast (Fig 3) showed pericardial effusion with mediastinal lymph nodes. Sputum analysis was negative for AFB. Pericardiocentesis under echo guidance showed straw colored fluid. There were no malignant cells and it was lymphocyte rich fluid. The AFB stain, TB culture and TB PCR were negative. Pericardial window was done and the biopsy showed chronic inflammation. No granuloma. The patient was treated with oral prednisolone and Anti-TB medications for 6 months with improvement both radiological and clinical. Follow up study: limited study with minimal effusion, follow up CXR shows resolution of the effusion. Conclusion: As rightly stated by Ewart and shown in our case there was at compression of the left lower lobe correlating with the clinical Ewart sign.