Primary Cardiac Lymphoma Presenting as Recurrent Pericardial Effusion and Tamponade

Primary cardiac lymphoma is a rare cause of pericardial effusion and tamponade that can present without a solid mass. An 85-year-old frail man with ischemic cardiomyopathy presented with tamponade from an isolated, rapidly enlarging hemorrhagic pericardial effusion. Fluid cytology and positron emission tomography-computed tomography confirmed human herpesvirus 8-negative, effusion-based large B-cell lymphoma. Given his high surgical risk and comorbidities, a tissue biopsy was avoided. He was managed with low-dose palliative chemotherapy and adjunctive intrapericardial triamcinolone, which successfully halted persistent high-output drain output, allowing safe pericardial drain removal and pericardial effusion control without invasive surgery. This case demonstrates that effusion-based lymphomas can occur without mass lesions or overt immunosuppression. It highlights the utility of fluid cytology over invasive biopsy in frail patients, and showcases intrapericardial steroids as a conservative tool to control refractory malignant drain output. Conservative management of primary cardiac lymphoma combining systemic chemotherapy with intrapericardial steroids may help delay or avoid high-risk surgical procedures in frail patients.