"Hypoglycemic episode" including facial twitching.

The patient is a 60-year-old African-American female with a past medical history significant for insulin-dependent diabetes mellitus type II, hypertension, and dialysis- dependent end-stage kidney disease for an unknown period of time. She has a history of hypoglycemic episodes and of often missing dialysis appointments. She also has a history of asbestos exposure at an unknown time. The patient was at the courthouse when she suddenly felt unwell and had an episode of facial twitching. According to the family, this was a typical symptom of her hypoglycemic episodes. She had missed her last dialysis appointment. Emergency medical services were called. The patient's Dextrostix reading was 37 in the field. She was subsequently given glucagon and transported to The Johns Hopkins Hospital emergency department

Dialysis Dependent End Stage Renal disease, last dialysis 4 days prior to admission
Type II Insulin Dependent Diabetes Mellitus
Hypertension
Hypoglycemia
Cataracts

Unknown

Unknown, was not reported by the patient

Dialysis every Tuesday, Thursday, Saturday; glipizide, metformin, amlodipine, Lipitor, PhosLo, Robitussin A-C, Allegra-D, folate, insulin 70/30 5 units twice a day, Atrovent, labetalol 100mg daily, Claritin, Nephrovite Compazine, quinine 325mg daily, Zantac 150mg nightly, Avandia 8mg daily, tramadol 50mg twice a day, and Nasacort 1-2 sprays daily.

Erythromycin, penicillin, sulfa and tetracycline

Not documented

• Weight: 104.5kg Height: 182cm T: 97.1 BP: 150/68 pulsus paradox: 9-11; P: 78
• General: Lethargic African-American woman with somewhat slurred speech
• HEENT: Dry oral mucosa, pupils were irregular with a surgical pupil.
• CV: JVP was noted to be elevated. Cardiac exam otherwise regular with no mumurs or rubs.
• Lungs: Course bilateral breath sounds.
• Abdomen: Soft with diffuse tenderness.
• Extremities: Some bilateral lower extremity hyperpigmentation with no edema.
• Mental Status: oriented to person, place and the hospital, but not time.
• Motor: 4/5 throughout, but not fully cooperative

• Na 132; K 5.5; Cl 93; BUN 47; Cr 8.3; Glucose 444; Calcium 9.0; Total Protein 7.3; Albumin 2.7; TBili 1.2, ALT 26; AST 31; Alk Phos 8.5
• WBC 12870 (90% Neutrophils, 3% lymphocytes); RBC 3.95; Hemoglobin 11.4; Hct 44.7; MCV 113.2; Platelet 380
• Troponin 1.56, CK-MB 4, total CK 70
• Urine: cloudy & brown, glucose (-), ketones (-), pH 7.0, protein 3+, leukocyte esterase (moderate), nitrite+,

See below

On admission to the ED (December 10), the patient was found to be somnolent and hypoglycemic with Dextrostix=52 and 39. She was given D50 in the emergency department with subsequent Dextrostix reading of 370. Her electrocardiogram was found to have ST changes in lateral and anterior leads and her troponin level was increased at 1.56. Also of note, she had missed her last dialysis appointment and was found to have hyperkalemia. She was given Kayexalate with plans to dialyze the next day. A Foley catheter was placed with dark, cloudy urine expressed. She was diagnosed with a urinary tract infection and started on gatifloxacin. She was admitted to the medicine department on December 11 and started on a beta-blocker, aspirin, heparin and nitroglycerin. Her aPTT was 1.5x control. Subsequent troponins were 1.66, 1.85. Repeat ECGs showed no ST elevation. She was dialyzed on December 11. Her hematocrit in the emergency department was 44.7, but decreased to 35.0 the next day.

An echocardiogram was performed on December 12 due to her increased troponin level and showed an ejection fraction of 30-35%, inferior wall dyskinesia and a large pericardial effusion measuring 2.6 cm posteriorly without evidence of tamponade. E to A reversal was noted suggesting impaired LV relaxation. There is mild mitral annular calcification. There was mild mitral regurgitation. There was trace tricuspid regurgititation. Doppler findings suggested moderate pulmonary hypertension. There was moderate aortic valve calcification. No valvular aortic stenosis was noted. She was again dialyzed on December 12.

On the morning of December 13, the patient was found in asystolic cardiac arrest. She was intubated and received epinephrine, atropine, and cardioversion with brief resolution of sinus rhythm without meaningful blood pressure. The patient died at 05:05AM on December 13.

Image 1: PA chest radiograph on admission, December 10: Cardiomegaly, small right pleural effusion. Right pleural plaque consistent with history of asbestos exposure. Linear calcification ascending aorta and aortic arch, cannot rule out telangiectasia or syphilis. Multiple bilateral chest wall radiodensities, possible vascular or lymphatic calcifications. No comparison film available.

Image 2: PA chest radiograph, December 13: Cardiomegaly (water bottle) compatible with pericardial effusion in addition to cardiomegaly. Calcified descending and aortic arch as well as arteriosclerosis descending aorta. Minimal to moderate left hemidiaphragm elevation with probable overlying nearby left lower lung partial atelectasis.

What was the cause of the patient's pericardial effusion?
What was the likely cause of the patient's cardiac arrest?