Telemedicine-Guided Pericardiocentesis for Cardiac Tamponade in Primary Mediastinal Large B-cell Lymphoma

Pericardial effusion has infectious, inflammatory, neoplastic, traumatic, cardiac, vascular, and idiopathic causes.When effusion accumulates rapidly enough to compromise ventricular filling, cardiac tamponade develops and becomes a life-threatening emergency requiring urgent drainage, a procedure conventionally performed by a cardiologist or cardiothoracic surgeon and rarely available on site at rural or resourcelimited hospitals.Malignant pericardial effusion is most often attributed to lung and breast carcinoma, while lymphoma is the leading hematologic cause.Tamponade as the presenting feature of non-Hodgkin lymphoma, however, is distinctly uncommon.We describe a 40-year-old man from a rural community in Nuevo León, Mexico, with three weeks of intermittent chest tightness, diaphoresis, unquantified fever, and approximately 7 kg of unintentional weight loss, followed by progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.He presented to a rural hospital with jugular venous distension, muffled heart sounds, and lower-limb edema, without pulsus paradoxus.Echocardiography demonstrated a severe pericardial effusion measuring up to 4.6 cm with tamponade physiology.With no cardiologist on site and hemodynamic collapse imminent, an internist performed pericardiocentesis under real-time telemedicine guidance from a cardiologist, draining serosanguineous fluid whose biochemical profile suggested tumor involvement.Contrast-enhanced chest computed tomography at the referral center revealed a 14.4 × 11.8 × 11.3 cm anterior mediastinal mass with necrotic areas.Video-assisted thoracoscopic surgery allowed pericardial window creation and tumor biopsy, which established a CD20-positive primary mediastinal large B-cell lymphoma (PMBCL).Chemotherapy with R-CHOEP (rituximab, cyclophosphamide, doxorubicin, vincristine, etoposide, and prednisone) was initiated, with resolution of hemodynamic instability and no recurrence of tamponade during the reported follow-up.This case illustrates that malignancy warrants early consideration in unexplained tamponade and that realtime telemedicine guidance may allow a non-specialist physician to undertake a life-saving bedside procedure where specialist care is otherwise unavailable, an approach that merits further evaluation in rural and underserved settings.