Managing malignant recurrent pericardial effusion in a palliative patient with bleomycin sclerotherapy

Rationale: Malignant pericardial effusion (MPE) is a life-threatening complication of advanced malignancies that frequently causes cardiac tamponade and severe functional decline. While pericardiocentesis provides acute relief, recurrence rates remain high. Intrapericardial sclerotherapy offers a minimally invasive approach to prevent reaccumulation and improve quality of life in palliative patients. Here, we report a case of recurrent MPE secondary to lung cancer successfully managed with intrapericardial bleomycin (BLM) pericardiodesis. Patient concerns: A 50-year-old male chronic smoker with advanced lung cancer and pericardial metastasis presented with progressive dyspnea, pleuritic chest pain, and cough due to recurrent cardiac tamponade. Initial emergency pericardiocentesis provided temporary palliation, but the effusion recurred within 2 months. Diagnoses: Echocardiography and chest imaging confirmed recurrent pericardial effusion with hemodynamically significant tamponade physiology. Cytological analysis of pericardial fluid revealed metastatic carcinoma consistent with lung cancer origin. Interventions: Emergency pericardiocentesis was performed, draining approximately 1000 ml of hemorrhagic fluid. Following confirmation of minimal residual effusion on repeat imaging, chemical pericardiodesis was performed via intrapericardial instillation of 10 mg BLM diluted in normal saline through a pigtail catheter, with the catheter clamped for 48 hours. Outcomes: The procedure was well tolerated without adverse effects. Follow-up echocardiography confirmed complete resolution of pericardial effusion. The patient experienced substantial symptomatic improvement in breathlessness, chest pain, and overall comfort, with no evidence of recurrence on subsequent follow-up. Lessons: This case underscores the safety and efficacy of intrapericardial BLM as a palliative intervention for recurrent MPE. It demonstrates the value of minimally invasive chemical pericardiodesis in preventing recurrence, enhancing quality of life, and avoiding the burden of repeated procedures; particularly relevant in resource-limited settings.