Abstract: PUB086
Cardiac Tamponade with Modestly Elevated Blood Urea Nitrogen (BUN): Atypical Presentation of Uremic Pericarditis in a Noncompliant Patient on Dialysis
Session Information
Category: Dialysis
- 801 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Fahim, Peter, HCA Florida West Hospital, Pensacola, Florida, United States
- Maheshwari, Priya Kumari, HCA Florida West Hospital, Pensacola, Florida, United States
- Goldsmith, William W., HCA Florida West Hospital, Pensacola, Florida, United States
- Issac, Maro, German University in Cairo, New Cairo City, Cairo Governorate, Egypt
- Sabra, Michel J., HCA Florida West Hospital, Pensacola, Florida, United States
Introduction
Uremic pericarditis is an uncommon but potentially life-threatening complication of ESKD. While typically associated with high BUN levels, it may present even with modest elevations. This case illustrates an atypical presentation complicated by cardiac tamponade and highlights the pivotal role of point-of-care ultrasound (POCUS) in early diagnosis and management.
Case Description
A 61-year-old male with ESKD on intermittent hemodialysis (noncompliant) presented with progressive shortness of breath, nausea, and abdominal discomfort. His history included chronic obstructive pulmonary disease on home oxygen, hypertension, diiabetes mellitus, and heart failure with preserved ejection fraction.
Vitals showed a blood pressure of 86/50 mm Hg, heart rate of 63 bpm, and oxygen saturation of 98% on 5L nasal cannula. Examination was notable for altered mental status, muffled heart sounds, diminished breath sounds bilaterally, abdominal distension, and bilateral pitting edema.
Laboratory results showed BUN 49 mg/dL, creatinine 9.03 mg/dL, potassium 5.3 mmol/L, phosphorus 6.2 mg/dL, WBC 12.5 K/μL, hemoglobin 9.4 g/dL, and a negative high-sensitivity troponin. EKG showed diffuse ST-segment elevations, and chest X-ray demonstrated cardiomegaly. POCUS revealed a large pericardial effusion with right ventricular diastolic collapse, consistent with cardiac tamponade.
Despite fluid resuscitation, hypotension persisted, requiring norepinephrine. Due to respiratory distress and inability to lie flat, an emergent subxiphoid pericardial window was performed, draining 600 mL of serous fluid. Hemodynamics improved postoperatively. Pericardial fluid was negative for infection, malignancy, or autoimmune disease. The patient resumed hemodialysis, the chest tube was removed on postoperative day 4, and he was discharged home in stable condition on day 6.
Discussion
This case highlights key teaching points. First, it challenges the dogma that elevated BUN is mandatory for uremic pericarditis, this patient developed tamponade with a BUN of only 49 mg/dL, suggesting toxin duration and uremic burden matter more than absolute levels. Noncompliance with dialysis may worsen this mismatch.
Second, it underscores POCUS’s critical role in rapidly diagnosing tamponade at the bedside, especially in unstable ESKD patients.