CONGRESS ABSTRACT

C. F., 70 y.o, male, presented to the NOA Hospital (Massa (MS), Tuscany, Itay) Emergency Department (ER) on Novembre, the 2nd at 3:21 p.m. complaining of chest and neck pain. He was suffering from metastatic melanoma already unsuccesfully treated with surgery and adjuvant immunotherapy (nivolumab), at the time in treatment with imatinib (an inhibitor targeting multiple tyrosine kinases). Some years before a routine echocardiogram had shown an ascending aorta aneurysm (maximal diameter of the ascending aorta 49 mm, 45 mm at the sinuses of Valsalva) with regular follow-up. Vital parameters were normal: T 36 °C, sAO2 99%, HR 84 bpm, RR 14 r/min, BP 120/60 mmHg. Arterial blood gas (ABG) analysis was normal. Blood tests revealed mild anemia (Hb 9.9 g/dl, r.v. 13.7-16.5), minimal alteration of C-reactive protein (0.76, r.v. >0.5) and high sensitivity troponin (17.4 ng/L and 18.6 ng/L after 2 hours), white blood cell count and fibrinogen were normal. ECG showed a normal sinus rhytm with 0.5 mm ascending ST elevation in inferior leads. Echocardiography excluded the presence of left ventricle regional wall motion abnormalities and confirmed the presence of an enlarged ascending aorta (maximal diameter was not dissimilar in comparison to the previous echocardiogram). Computed tomography (CT) angiography ruled out acute aortic syndrome and no pericardial effusion was present. The patient was discharged at 19:26, proton pump inhibitors and acid inhibitor prescribed. On November, the 3rd at 10:07 a.m., only 10hrs and 41 mins after discharge, the patient presented to the ER with shock. At night he suffered of fever (T 39 °C). His BP and sAO2 were very low (60/40 mmHg and 90% respectively). ABG analysis showed mild lactyc acidosis (Lac 2.3 mmol/L). ECG showed a 4 mm ST segment elevation in leads DII-DIII-aVF-V5-V6 and ST segment depression in leads V1-V2. An echocardiogram was performed and a severe pericardial effusion with pericardial tamponade diagnosed. The patient was promtly treated with fluid, high-dose vasopressor and oxygen therapy. Urgent pericardial drainage removed 200 ml of cytrine fluid. Chemycal-physical analysis pointed out the presence of trasudate, pathology exam for metastatical cancer cells and viral tests were negative. The clinical course was regular and after 12 days the patient discharged. Imatinib was interrupted since fluid retention with pleural and pericardial effusion is a known side effect of tirosikne kinase inhibitors even if very rare.