If the effusion is small, there may be no symptoms as all, but as it accumulates the patients begin to have symptoms of dyspnea, that worsens over time, with an associated tachycardia. There may be symptoms of chest pain that is relieved on leaning forward. Some patients may report lightheadedness with syncope or near syncope. Symptomatic patients usually have evidence of right side heart compromise that may be assessed on echocardiography.

On examining the patient, there may be the classic triad of hypotension, decreased heart sounds and signs of increased jugular venous distension. There may be a pericardial friction rub and a positive hepatojugular rub. Pulsus paradoxus may occur which is defined as a drop of the systolic blood pressure of more than 10mmHg on inspiration due to falling cardiac output. Ewarts sign (Dullness to percussion under the angle of the left scapula) may be positive [6].

• Inflammation

  But if the pericardium is diseased or injured, the resulting inflammation can lead to excess fluid. Fluid can also build up around the heart without inflammation, such as from bleeding after a chest trauma. [mayoclinic.com]

  • Accumulation of fluid in the pericardial cavity • Causes include - Trauma, inflammation, hemorrhage, infection, cancer, radiation therapy, kidney failure, autoimmune disorder and idiopathic • If the onset is rapid or the volume is large, it may cause [quizlet.com]

  Pericarditis is an inflammation of the pericardium, the sac that covers the heart. The inflammation can result in an acute condition that causes chest pain that intensifies with breathing and malaise. [houstonmethodist.org]

  For pericardial effusions due to inflammation of the sac, treating the inflammation also treats the effusion. [webmd.com]

• Swelling

  Food, medications, insect or bee stings, and even infections can cause allergic reactions that lead to facial swelling. Facial swelling due to a serious allergic reaction can be dangerous if the airway swells up. [healthline.com]

  This may lead to swelling. Aging : As a person ages their body expels more water throughout the day. This can lead to the body trying to retain more fluid, causing swelling around the eyes. [medicalnewstoday.com]

• Myxedema

  Abstract INTRODUCTION "Myxedema heart" was first described as a clinical entity by Zondek 1 in 1918. [annals.org]

  Echocardiographic evaluation of pericardial effusion in myxedema. Incidence and biochemical and clinical correlations. Circulation 1975; 52: 823-7. [ Links ] 3. Parving HH, Hansen JM, Nielson SL, Rossing N, Munck O, Lassen NA. [scielo.br]

  […] tuberculous, or idiopathic in origin) Autoimmune disease Postmyocardial infarction or cardiac surgery; sharp or blunt chest trauma, including a cardiac diagnostic or interventional procedure Malignancy, mostly metastatic; chemo, radiation to the chest Uremia; Myxedema [slideshare.net]

  Idiopathic Infection Autoimmune (SLE, rheumatoid arthritis, scleroderma) Dressler's and postpericardiotomy syndromes Neoplasm (lymphoma, lung or breast metastasis) Drug-induced (procainamide, hydralazine, phenytoin) Uremia Myxedema Congestive heart failure [stritch.luc.edu]

• Pleural Effusion

  KEYWORDS: Acute pancreatitis; pericardial effusion; pleural effusion [ncbi.nlm.nih.gov]

• Dyspnea

  Emergency physicians must maintain vigilance in suspecting pericardial effusion and tamponade in patients with known or suspected malignancy who present with tachycardia, dyspnea, and hypotension. [ncbi.nlm.nih.gov]

  Clinical Presentation Significant symptoms only present with effusion leading to tamponade fatigue, dyspnea, chest discomfort, elevated jugular venous pressure, edema ECG findings — most commonly – sinus tachycardia, low QRS voltage, and electrical alternans [slideshare.net]

  Assessment should include the impact of dyspnea on the patient’s functional status and appreciation of the dynamic component of dyspnea—namely, exertional dyspnea. [cancer.gov]

• Cough

  Symptoms may arise gradually or rapidly, depending on fluid accumulation rate, and may range from dyspnoea, chest pain, cough, palpitations and orthopnoea, to fatigue, anxiety and confusion. [oncologypro.esmo.org]

  Symptoms of Pericardial Effusion There are many symptoms of this condition including: Shortness of breath or difficulty breathing Discomfort when breathing while lying down Chest pain Cough Low-grade fever Rapid heart rate Treatment of Pericardial Effusion [houstonmethodist.org]

  Symptoms may include: Rapid heart rate Chest pain, which worsens when when you take a breath or when you’re lying down Shortness of breath or difficulty breathing, especially when you’re lying down Nausea Coughing Low-grade fever Difficulty swallowing [dignityhealth.org]

  A 30-year-old black man was admitted with complaints of nonproductive cough and a 9.08-kg (20-lb) weight loss over the past two months. He was treated with oral antibiotics on two different occasions with no relief of symptoms. [aafp.org]

• Tachypnea

  We report a rare case of complicated pericardial effusion due to E. meningoseptica in a 2-year-old boy, who was admitted with chief complaints of fever and tachypnea (mentioned by his parents) and suffered from a rare lung malignancy (lymphangioleiomyomatosis [ncbi.nlm.nih.gov]

  2-4 mm Clinical Findings Small effusions frequently produce no symptoms Chest pain or discomfort with a characteristic of being relieved by sitting up or leaning forward and worsened in the supine position\ Syncope Palpitations Shortness of breath, tachypnea [learningradiology.com]

  On admission the patient was pale, with dilated jugular veins, abdominal respiration with tachypnea (30 breaths/min), tachycardia (150 beats/min), and pulsus paradoxus (20 mmHg), while his blood pressure was with in normal range (100/60 mmHg). [wjso.biomedcentral.com]

  Common associated signs and symptoms include low-grade intermittent fever, dyspnea/tachypnea (a frequent complaint and may be severe, with myocarditis, pericarditis, and cardiac tamponade), cough, and dysphagia. [pdfslide.us]

  Tachypnea and dyspnea on exertion that progresses to air hunger at rest are the key symptoms, but it may not be possible to obtain such information from patients who are unconscious or obtunded or who have convulsions at presentation. [rjmatthewsmd.com]

• Orthopnea

  If pericardial effusion symptoms do occur, they might include: Shortness of breath or difficulty breathing (dyspnea) Discomfort when breathing while lying down (orthopnea) Chest pain, usually behind the breastbone or on the left side of the chest Chest [mayoclinic.com]

  The pressure from the outside causes the blood to pool back and accumulate in the lungs which causes the symptoms of orthopnea and dyspnea. [pericarditispain.info]

  […] shifts towards the left ventricle chamber → ↓ ventricular diastolic filling → ↓ stroke volume (+ venous congestion) → ↓ cardiac output References:[2] Clinical features Usually initially asymptomatic Shortness of breath, especially while lying down (orthopnea [amboss.com]

• Nausea

  These include: Chest pressure or pain Shortness of breath or painful breathing even with limited activity Rapid or irregular heartbeat or pulse Dizziness or fainting Nausea or abdominal fullness Fever Symptoms showing that pericardial effusion may be [wellstar.org]

  Symptoms may include: Rapid heart rate Chest pain, which worsens when when you take a breath or when you’re lying down Shortness of breath or difficulty breathing, especially when you’re lying down Nausea Coughing Low-grade fever Difficulty swallowing [dignityhealth.org]

  These include: Lightheadedness or dizziness Cool arms and legs Clammy skin Weakness Rapid breathing Nausea or vomiting Pale skin Less urine output Shock is a medical emergency. [cedars-sinai.org]

  Lightheadedness/Fainting Confused or impaired thinking Nausea and/or vomiting Decreased urine output Anxiety Swelling of the legs or abdomen Diagnosis of Pericardial Effusion The clinical diagnosis of pericardial effusion is usually based on the patient [rwjbh.org]

  […] occur due to diastolic heart failure (heart failure that occurs because the heart is unable to relax normally between each contraction due to the added compression).Symptoms of pericardial effusion include: Chest pressure or pain Shortness of breath Nausea [my.clevelandclinic.org]

• Vomiting

  The two patients, 13- and 14-year-old boys, developed cardiomegaly and chest pain with vomiting. On examination by two-dimensional echocardiography, thickening of the ventricular septum and a pericardial effusion were detected. [ncbi.nlm.nih.gov]

  Other gastrointestinal signs such as gagging or vomiting may be present. Ascites (fluid buildup in the abdomen), episodes of collapse or difficulty breathing may also be present. [bluepearlvet.com]

• Dysphagia

  Dysphagia- due to compression of esophagus Nausea and abdominal discomfort- due to pressure of sub-diaphragmatic structure Hiccups- due to compression of the phrenic nerves Physical examination - 1. [iame.com]

  He had no history of congestive heart failure or dysphagia. [wjso.biomedcentral.com]

  Common associated signs and symptoms include low-grade intermittent fever, dyspnea/tachypnea (a frequent complaint and may be severe, with myocarditis, pericarditis, and cardiac tamponade), cough, and dysphagia. [pdfslide.us]

  That can cause symptoms like: Trouble swallowing (dysphagia). Hiccups. Coughing or hoarseness. What causes pericardial effusion? Pericardial effusion can happen for many different reasons. [my.clevelandclinic.org]

  Most patients are weak and faint at presentation and can have vague symptoms such as anorexia, dysphagia, and cough. The initial symptom may also be one of the complications of tamponade, such as renal failure. [rjmatthewsmd.com]

• Diarrhea

  Other symptoms may include: Fever Fatigue Muscle aches Shortness of breath Nausea, vomiting, and diarrhea (if you have a virus) When there’s no inflammation of the sac, there are often no symptoms. [webmd.com]

  Shortness of breath Fatigue Fever Nausea Muscle aches Vomiting and diarrhea, which are signs that a viral infection is present. However, in cases where the effusion is not caused by pericarditis, the symptoms are less pronounced. [docdoc.com.sg]

  She denies polyuria, polydipsia, weight changes, diarrhea, or vomiting. Physical examination reveals left periorbital erythema with temporal soft-tissue swelling that is tender to palpation. [pedsinreview.aappublications.org]

  Chronic functional problems after gastric surgery include dumping syndrome, acid or bile regurgitation, post-vagotomy diarrhea, and gastroparesis. [kiss.kstudy.com]

• Chest Pain

  We discuss the case of a 40-year-old male ultramarathon runner with RA who presented with mild pleuritic chest pain and exertional dyspnoea after a recent long-haul flight. [ncbi.nlm.nih.gov]

  Convert to ICD-10-CM : 423.9 converts approximately to: 2015/16 ICD-10-CM I31.9 Disease of pericardium, unspecified Approximate Synonyms Chest pain due to pericarditis Chest pain of pericarditis Lyme myopericarditis Myopericarditis due to lyme disease [icd9data.com]

• Heart Failure

  Presenting symptoms include heart failure, arrhythmias, sudden death, cyanosis and chest pain. But it can also present as recurrent pericardial effusion misdiagnosed as tuberculosis and other infectious causes. [ncbi.nlm.nih.gov]

  […] are no other signs of heart failure Whenever the heart appears globular, it could be due to a pericardial effusion – the diagnosis can be confirmed using ultrasound (echocardiogram) Malignant pericardial effusion Hover on/off image to show/hide findings [radiologymasterclass.co.uk]

  Another clue is the rapid change in heart size or presence of cardiomegaly without the radiographic findings of congestive heart failure (pulmonary edema, etc.) Posterior displacement of epicardial fat pad by effusion. Pulmonary olegemia. [stritch.luc.edu]

  Diuretics and other heart failure medications can be used to treat pericardial effusions caused by heart failure. Antibiotics are used to treat pericardial effusions caused by an infection. [my.clevelandclinic.org]

• Tachycardia

  Emergency physicians must maintain vigilance in suspecting pericardial effusion and tamponade in patients with known or suspected malignancy who present with tachycardia, dyspnea, and hypotension. [ncbi.nlm.nih.gov]

  Clinical Presentation Significant symptoms only present with effusion leading to tamponade fatigue, dyspnea, chest discomfort, elevated jugular venous pressure, edema ECG findings — most commonly – sinus tachycardia, low QRS voltage, and electrical alternans [slideshare.net]

  Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. [amboss.com]

• Hypotension

  Emergency physicians must maintain vigilance in suspecting pericardial effusion and tamponade in patients with known or suspected malignancy who present with tachycardia, dyspnea, and hypotension. [ncbi.nlm.nih.gov]

  Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. [amboss.com]

  These three signs (hypotension, muffled heart sounds, and jugular distension) are known as the classic Beck triad of cardiac tamponade. [study.com]

  […] pressure and mild hypotension 7. [slideshare.net]

• Pulsus Paradoxus

  Constrictive pericarditis shall refer to a combination of physical and echocardiographic findings (i.e., patients with a prior history of pericardial effusion who have pulsus paradoxus, a raised jugular venous pressure with or without evidence of pericardial [clinicaltrials.gov]

  Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. [amboss.com]

  Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers [jamanetwork.com]

  The absence of pulsus paradoxus (Table 1) makes this form difficult to recognize. [rjmatthewsmd.com]

  Pulsus paradoxus reflects a decrease in systolic BP with inspiration of more than 12 mm Hg. Pulsus paradoxus also occurs in severe asthma or COPD exacerbations. Treatment Many pericardial effusions do not require any therapy. [healio.com]

• Hepatomegaly

  Radiologic examinations were carried out, and the computed tomography scan revealed a hepatomegaly and a chest X-ray showed evidence of a unilateral pleural effusion. [ncbi.nlm.nih.gov]

  For example, systolic blood pressure was higher than 100 mm Hg in 94% of patients, elevation of the jugular venous pressure was found in only 74%, hepatomegaly was present in 28%, and pulsus paradoxus was found in only 36% of patients. [heart.bmj.com]

  Symptoms and signs of peripheral venous congestion (eg, peripheral edema, neck vein distention, hepatomegaly) may appear with an early diastolic sound (pericardial knock), often best heard during inspiration. [merckmanuals.com]

• Confusion

  So why is measuring an effusion a potentially confusing measurement? There can be significant variability in the linear dimension of fluid throughout the cardiac cycle. [echo.guru]

  Symptoms may arise gradually or rapidly, depending on fluid accumulation rate, and may range from dyspnoea, chest pain, cough, palpitations and orthopnoea, to fatigue, anxiety and confusion. [oncologypro.esmo.org]

  Lightheadedness/Fainting Confused or impaired thinking Nausea and/or vomiting Decreased urine output Anxiety Swelling of the legs or abdomen Diagnosis of Pericardial Effusion The clinical diagnosis of pericardial effusion is usually based on the patient [rwjbh.org]

  Pleural fluid can be confused with a pericardial effusion and can be distinguished by its appearance behind the descending aorta on the parasternal long axis view of the heart. An epicardial fat pad can also be confused with pericardial fluid. [merckmanuals.com]

• Headache

  Register Infectious Disease Rounds: Headache, Fever, and Periorbital Edema - 24 Hours access EUR €27.00 GBP £20.00 USD $35.00 Rental This article is also available for rental through DeepDyve. [academic.oup.com]

  His systemic medical history included migraine headaches without aura for which he was taking oral sumatriptan 100 mg once a day and oral nortriptyline 50 mg once at bedtime. [healio.com]

  She had tremendous headaches and so much pain in her chest, neck, shoulders, and upper back that she couldn’t care for herself. I feared she was dying. [americannursetoday.com]

  Nesheiwat says if you have any headaches, bruising, or bleeding, you need to see a doctor immediately. External signs and symptoms, such as bruising or bleeding can also indicate an internal facial or head injury. [healthline.com]

• Asthenia

  The patient also reported asthenia and lower limb, facial, and abdominal edema, but denied the existence of any other health problem except depression (untreated for the last few months). She was previously hospitalized for dyspnea. [scielo.br]

  Signs and symptoms of PMR include severe, symmetrical pain and stiffness in the neck, shoulder, and pelvic girdles, along with painful restriction of motion, malaise, anorexia, weight loss, moderate fever, asthenia, difficulty rising from the bed and [americannursetoday.com]

  Dyspnea, fatigue, or asthenia may be the initial symptoms.[ 9 ] Symptomatic pericardial effusions are often a preterminal event; however, significant symptom palliation can be achieved by prompt diagnosis and management. [cancer.gov]

• Altered Mental Status

  CASE REPORT We present a case of a 61-year-old man with metastatic small cell lung cancer undergoing chemotherapy who presented with fatigue, poor appetite, and altered mental status. [ncbi.nlm.nih.gov]

  Before additional laboratory studies and imaging could be obtained, the patient developed altered mental status, hypotension, and paralysis of the lower extremities. [mdedge.com]

Initial workup will include an electrocardiogram which may show:

• Low voltage 
• Electric alterans 

A chest X-ray may show an enlarged globular heart. Echocardiogram is the most sensitive test for pericardial effusion and will also provide information about the estimated amount, the function of the ventricle and if they have been compromised by the effusion. The effusions are graded as mild (50-100mls), moderate (100-500mls) and severe (>500mls).

Establishing the cause is important in symptomatic effusions. This will entail ruling out the causes as listed in the etiology section and will require echocardiogram assisted pericardial effusion aspiration. The fluid is sent for the relevant tests for the underlying cause to be identified. MRI and CT Scan may be used to access the presence of effusion [7].

• Atelectasis

  A comprehensve CT Chest App. that include chest anatomy and pathollogy as well as various CT chest types CT Chest Types CT Chest Anatomy Abnormalities of the Trachea Abnormalities of the Lung Hilum Consolidation Interstitial disease Atelectasis Aortic [play.google.com]

  Ewart’s sign is dullness to percussion at the left lung base due to compressive atelectasis from a large pericardial effusion. Auenbrugger’s sign is an epigastric bulge due to a large pericardial effusion extending subxiphoid. [healio.com]

  In patients with pleural effusion, thickening of the pericardium, lung collapse (atelectasis) and in patients with excessive fat tissue around the heart. CT Scan Computed tomography (CT) scan has the advantage of detecting small quantity effusions. [healthhype.com]

• Cardiomegaly on Chest X-ray

  We suggest that any patient who develops chest pain, tachycardia, cardiomegaly on chest X-ray or has signs of hypoxemia should be evaluated for PEF through echocardiography and tested for laboratory signs of TA-TMA. 10 Patients diagnosed with a moderate-to-large [nature.com]

  ECG may show low voltage complexes and electrical alternans, and cardiomegaly on chest X-ray [2,12,16]. [escardio.org]

• X-Ray Abnormal

  […] ordered when someone has some combination of the following signs and symptoms : Chest pain, sharp or sometimes dull, that may be relieved by bending forward Coughing Difficulty breathing Fever Fatigue Changes in heart rhythm Enlarged heart size on chest X-ray [labtestsonline.org]

• Chest X-Ray Abnormal

  […] on chest X-ray Abnormal pericardial appearance on echocardiogram Test results can help distinguish between types of pericardial fluid and help diagnose the cause of fluid accumulation. [labtestsonline.org]

• Echocardiogram Abnormal

  Estonian Südametamponaad (perikardi verejooks) English Cardiac tamponade (pericardial haemorrhage) Last Update: 2017-04-26 Usage Frequency: 1 Quality: Reference: Wikipedia Estonian perikardi efusioon ehhokardiogrammi muutused English pericardial effusion echocardiogram [mymemory.translated.net]

• Chlamydia

  Rubella, Mumps, HBV, HCV, HIV, Parvovirus B19 and Human Herpes Virus 6 (increasing reports) Bacterial [most common: tuberculous (4–5%), Coxiella burnetii, other bacterial rare may include Pneumo-, Meningo-, Gonococcosis, Haemophilus, Staphylococci, Chlamydia [eurheartj.oxfordjournals.org]

  HBV, HCV, HIV, parvovirus B19, and human herpes virus 6 (increasing reports) Bacterial (most common: tuberculous [4%–5%], Coxiella burnetii ; other bacterial [rare] may include pneumococcosis, meningococcosis, gonococcosis, haemophilus, staphylococci, chlamydia [circ.ahajournals.org]

• Electrical Alternans

  Electrical alternans vs. pseudoelectrical alternans. [lifeinthefastlane.com]

  Diagnostics: Electrocardiogram See Cardiac Tamponade Low amplitude wave forms Electrical alternans VII. [fpnotebook.com]

• Pleural Effusion

  KEYWORDS: Acute pancreatitis; pericardial effusion; pleural effusion [ncbi.nlm.nih.gov]

Symptomatic effusion requires aspiration of the fluid, pericardiocentesis, and this may be done with ultrasound or echocardiogram guidance with drainage insertion. Pericardiocentesis has to be done rapidly in patients with compromised hemodynamics. Treatment of underlying causes such as tuberculosis is required to prevent reaccumulation [8] [9] [10].

The outcome is highly dependent on the cause. Most patients with acute pericarditis present with minimal effusions and many will have a self-limiting course. Viral causes as well are usually self-limiting and will heal with no long term complication. Other causes such a malignancy have poor outcomes. The mortality of HIV patients that have symptomatic effusions is low. If the patient is in cardiac tamponade, this has to be relieved or it could be fatal.

There are many causes of a possible pericardial effusion.

• Acute pericarditis 
• Viral causes such as varicella zoster virus (VZV), coxsackievirus A or B, influenza virus, herpes simplex virus, adenovirus, cytomegalovirus, Epstein-Barr virus, or human immunodeficiency virus (HIV)
• Mycobacterium 
• Whipple disease 
• Pyogenic causes such as streptococcus and staphylococcus
• Post myocardial infarction
• Malignancies such as lymphoma or direct spread of nearby tumor
• Uremia
• Traumatic 
• Autoimmune diseases, such as rheumatoid arthritis, sarcoidosis and systemic lupus erythematosus
• Myxedema
• Drugs like hydralazine, isoniazid, minoxidil, phenytoin, anticoagulants [1] [2]

Small pericardial effusions are usually not asymptomatic and have been found in some autopsy studies to have a prevalence of 3%. There are some subsets of patients who have an increased risk of pericardial effusion. These include those with lung cancer. Up to 21% of these patients may have an effusion. Patients with the human immunodeficiency virus have a higher incidence of effusions as well and it has been noted in up to 13% [3] [4].

The clinical manifestations of pericardial effusion are dependent on the rate of fluid accumulation. A rapid increase of a small amount of fluid may cause significant symptoms, but the pericardium may accomodate up to 2l slowly over time. The various causes listed above cause the pericardium to secrete more fluid by various methods, either by increased production or decreased absorption [5].

Prevention is difficult as there are numerous causes of effusion. Preventable causes include vaccinating against viruses that may cause the effusion. Otherwise appropriate management of underlying causes should be done (e.g appropriate dialysis for end stage renal disease patients)

The pericardium has several functions:

• Restraining force, that prevents sudden dilation of the cardiac chambers.
• Maintaining the anatomic position of the heart.
• Reduces friction between the heart and it surrounding structures. The small pericardial fluid which is an ultrafiltrate that acts a lubricant 
• Stops the spread of infections from the lungs and pleural cavities to the heart [1]

Pericardial effusions, abnormal accumulations of fluid in the pericardial space, may develop slowly or quickly. The normal pericardium can stretch slowly over time to accommodate a gradual increase in the fluid, but it has its limits and the accumulating fluid will exert its pressure on the heart and compromise its function (cardiac tamponade).

It may be sub-classified into:

• Acute effusion: < 6 weeks
• Subacute effusion: 6 weeks to >6months 
• Chronic effusion: > 6months 

• Definition: Pericardial effusion is the accumulation of fluid in the sac that encloses the heart. In most cases it is associated with inflammation, which could be caused by viruses most commonly. 
• Cause: There are many causes, which differ from country to country with some countries reporting cancers as the highest cause of symptomatic pericardial effusions. 
• Symptoms. This may include easy fatigability, difficulty in breathing, and sometimes fainting. There may be a cough, lightheadedness and awareness of a heart beat at fast heart rate. If the pericardial effusion is large enough, it can cause the heart to function poorly and fail, which may cause death if not treated well.
• Diagnosis: This is diagnosed with different methods but echocardiography (ultrasound of the heart) is the most widely used method. Other tests such as CT scans may be used. Some fluid may be taken for analysis, to try and find out the cause. 
• Treatment: If the symptoms are bad enough the doctor may remove the fluid to offer you some relief. Then they will try to find out the cause and treat it as required.

1. Spodick DH. The Pericardium: A Comprehensive Textbook, Marcel Dekker, New York 1997. p.260.
2. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717.
3. Lind A, Reinsch N, Neuhaus K, et al. Pericardial effusion of HIV-infected patients ? Results of a prospective multicenter cohort study in the era of antiretroviral therapy. Eur J Med Res. Nov 10 2011;16(11):480-3.
4. Meenakshisundaram R, Sweni S, Thirumalaikolundusubramanian P. Cardiac isoform of alpha 2 macroglobulin: a marker of cardiac involvement in pediatric HIV and AIDS. Pediatr Cardiol. Nov 14 2009;
5. Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol 1995; 75:378.
6. Sagristà-Sauleda J, Mercé J, Permanyer-Miralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med 2000; 109:95.
7. Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2013; 26:965.
8. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J 2013; 34:1186.
9. Kopecky SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardial catheter drainage: report of 42 consecutive cases. Am J Cardiol 1986; 58:633.
10. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and