Hemorrhagic nonspecific pericardial effusion as an initial symptom of angiosarcoma of the right heart

History A 45-year old woman presented at our hospital with intermittent fever in the last three weeks and progressive exertional dyspnea. in addition she suffered from physical asthenia. Seven months ago the patient was treated for symptomatic pericardial effusion in our clinic. Investigations Physical examination revealed a pale skin color, epigastric pain on palpation and intense exertional dyspnea. Laboratory tests indicated microcytic anemia and high levels of LDH and CRP. The diagnosis of a large tumor of the right atrium and ventricle was based on the transthoracic echocardiogram and thoracic CT scan. The extent of the right atrial and ventricular mass of 9 x 8 cm was detected by transesaphageal echocardiography. The thoracic and abdominal CT scan showed multiple nodular infiltrates in the basal lung fields and a cystic tumorous mass in the liver. Diagnosis The tumor developed in the short time of 7 months. Half a year ago, the transthoracic echocardiographic exam showed pericardial effusion with normal cardiac size, normal left ventricular function and no evidence of right ventricular outflow obstruction. No cardiac masses were observed. At that time pericardiocentesis was performed, but the pericardial fluid was cytologically negative for tumor cells. The diagnosis of angiosarcoma was made after surgical excision of the tumor and histological examination. There was only the possibility of a palliative therapy, because of the existence of pulmonary and liver metastases. Conclusions Primary malignant cardiac tumors are rare and their prognosis is very poor. The heart angiosarcoma is often disseminated into the lungs and the liver at the time of clinical presentation. This case indicates that hemorrhagic nonspecific pericardial effusion, negative for tumor cells, can appear any time before a heart angiosarcoma is detectible by echocardiography.