A rare case of improved diastolic function following subxiphoid pericardiostomy for cardiac tamponade in a hypertensive patient with dressler's syndrome and non-tuberculous hemorrhagic effusive pericarditis

This case report describes a 54-year-old hypertensive man with minor coronary artery disease (CAD; 30% stenosis in mid-LAD and RCA, managed medically with clopidogrel) and a recent history of non-tuberculous (Staphylococcus aureus) pneumonia who developed massive hemorrhagic effusive pericarditis (HEP) leading to cardiac tamponade. Hypertension, a major global cardiovascular risk factor, likely contributed to the underlying vascular and inflammatory milieu that predisposed the patient to this rare complication. Transthoracic echocardiography demonstrated a massive circumferential pericardial effusion (>20 mm diastolic separation) with tamponade physiology, including severely reduced left ventricular end-diastolic volume (LVEDV 52 mL, below the normal male reference range of 53–156 mL). Emergency subxiphoid pericardiostomy evacuated approximately 2000 mL of grossly hemorrhagic fluid, resulting in immediate hemodynamic stabilization. Post-procedure echocardiography confirmed complete effusion resolution and a significant 28.8% increase in LVEDV to 67 mL, documenting restoration of diastolic filling and normalization of previously impaired (restrictive-pattern) diastolic function. Pericardial fluid analysis revealed an exudative process (positive Rivalta test, protein 6.35 g/dL, LDH 1426 U/L, borderline ADA 26 U/L) with no bacterial growth on culture. Cytology and histopathology showed chronic inflammatory changes (dense lymphoplasmacytic infiltration) without malignancy. The patient improved clinically over an 11-day hospitalization and was discharged in stable condition. This rare presentation of cardiac tamponade secondary to HEP likely reflects overlapping mechanisms: autoimmune response consistent with Dressler’s syndrome (post-injury pericarditis following minor CAD, occurring ~4 weeks post-ischemic insult) and pericardial involvement from recent non-tuberculous pneumonia, exacerbated by antiplatelet therapy and the hypertensive state. The case underscores the reversibility of tamponade-induced diastolic dysfunction with prompt surgical drainage and highlights the need for advanced imaging (cardiac CT and MRI) to clarify etiology, monitor for recurrence (including constrictive pericarditis), and prevent future morbidity.