Case Study: Young Man With Malignancy Presents With Shortness of Breath

Case:

A 42-year-old man with no prior medical history was recently diagnosed with metastatic adenocarcinoma of the lungs when he presented with new onset seizures. A computed tomography (CT) brain scan revealed brain metastasis. He recently received gamma knife treatment and was status post his first cycle of chemotherapy when he presented to his primary care provider with exertional dyspnea that ultimately progressed to dyspnea at rest with near syncope.

Physical exam revealed hypotension, tachycardia, tachypnea, and jugular venous distention with distant heart sounds but no friction rub. Pre-chemotherapy lab work the day prior to presentation showed the following:

• C-reactive protein 0.8 mg/dL
• Low-density lipoprotein 169 mg/dL
• White blood count 9.8
• Hemoglobin 12 g/dL
• Hematocrit 37%
• Thyroid stimulating hormone 0.82 U/mL
• Alkaline phosphatase 146 IU/L
• Lymphocytes % 13.9 (L)
• Monocytes % 15 (h), platelets of 550
• Albumin 4.0 g/dL
• Total protein 7.8 g/dL 

He was sent for a chest x-ray which revealed a markedly enlarged cardiac silhouette. 

What is the most likely Diagnosis? 

1. Chemotherapy-induced cardiomyopathy and systolic heart failure
2. Worsening bilateral pleural effusions causing shortness of breath
3. Pericardial effusion with tamponade physiology
4. Radiation-induced pulmonary fibrosis
5. Pericardial constriction