Chapter 35: The fainting dancer

A 23-year-old professional dancer became faint and short of breath at the end of a performance. Her friends became worried and brought her to the emergency department where she had a chest X-ray.

• 1. What does the chest X-ray show?

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  Correct answer:
  

  Splayed carina (a feature of subcarinal lymph node enlargement)
  Mediastinal lymphadenopathy
  Globular heart

She was sent directly for a thoracic CT scan.

• 2. What does the CT scan show?

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  Correct answer:
  
  Pericardial effusion
  Anterior mediastinal lymphadenopathy
  

• 3. What emergency treatment may she need?

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  Correct answer:
  If she has cardiac tamponade (pressure on the ventricles in diastole prevents them from filling, thus reducing the stroke volume and cardiac output) this can be relieved by direct aspiration and drain insertion or by surgical drainage with formation of a pericardial window that connects the pericardium and pleural space. The classic sign of cardiac tamponade is Beck’s triad of hypotension because of decreased stroke volume, jugular-venous distension due to impaired venous return to the heart and muffled heart sounds due to fluid inside the pericardium.

CT scan and echocardiogram confirmed a significant pericardial effusion and she had a pericardial drain inserted. She subsequently had a CT-guided biopsy of the mediastinal lymphadenopathy. This demonstrated mediastinal sclerosing B-cell NHL.

There were no other sites of disease and she was referred to the teenage young adult principal treatment centre (TYA PTC). She was treated with six cycles of R-CHOP chemotherapy and achieved a complete metabolic response confirmed by CT-PET scanning. She is back performing as a dancer in West-End musicals.