Massive Pulmonary Embolism Concomitant With Cardiac Tamponade as Initial Presentation of Lung Adenocarcinoma: A Diagnostic and Therapeutic Dilemma.

Pulmonary embolism and cardiac tamponade are potentially fatal acute conditions that rarely present concomitantly in the emergency department (ED). Both require early diagnosis and urgent intervention, and are usually observed as separate easily identifiable diseases. However, in a patient exhibiting a concomitant presentation of pulmonary embolism with cardiac tamponade, diagnosis and therapeutic intervention are extremely challenging. A 48-year-old woman presented with cardiac tamponade as an initial symptom of an underlying lung adenocarcinoma and masked massive pulmonary embolism (MPE), which led to the development of sudden cardiac arrest after successful pericardiocentesis. She presented with a high index of suspicion for a diagnosis of MPE using echocardiography after successful pericardiocentesis, and this diagnosis was confirmed using computed tomography. Extracorporeal membrane oxygenation and adjusted-dose unfractionated intravenous heparin administration were performed; unfortunately, they were unsuccessful. This report would help ED physicians because this case demonstrates that lung cancer can initially present as pulmonary embolism with cardiac tamponade and pulmonary embolism can be misdiagnosed in the presence of concomitant cardiac tamponade. Bedside echocardiography may fail to diagnose life-threatening MPE with coexisting cardiac tamponade. MPE can also lead to the development of sudden cardiac arrest after successful pericardiocentesis. Thrombolytic and anticoagulant use in MPE with coexisting hemorrhagic cardiac tamponade is a controversial issue. The risk-benefit ratio of both therapies needs to be considered on a case-by-case basis for improved clinical outcomes.