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We report the case of a 69 years old woman, ex-smoker, with a history of hypertension, dyslipidemia, diabetes and right leg partial amputation after childhood osteomyelitis, presented at the emergency department for dyspnoea, posterior thoracic pain and progressive distention of the abdomen. She was tachycardic, slightly hypoxemic but normotensive. Electrocardiography: sinus tachycardia, normal axis, diffuse microvoltage and electric alternans. Chest X-ray showed enlarged cardiac silouhette, bilateral pleural effusion and upper right pulmonary lobe consolidation. Transthoracic echocardiography revealed large pericardial effusion, swinging heart, right atrial and right ventricular colapse, significant respiratory variation of transmitral and transtricuspidian flow, dilated inferior vena cava without respiratory variation, all suggesting cardiac tamponade. Computed tomography showed a mediastinal and pulmonary mass in the upper right pulmonary lobe, invading the posterior right thoracic wall and multiple mediastinal voluminous lymphadenopaty and ascites. She became hypotensive and was transferred to a tertiary hospital for urgent drainage of pericardial effusion. Over 1200 mL of serohematic fluid was evacuated with the removal of the drainage catheter in the following 48 hours. A biopsy was performed through bronchoscopy and small cell carcinoma of the lung was diagnosed. Considering the advanced stage of the carcinoma the option of pallative treatment was pursued. Discussions Chronic accumulation of large amounts of pericardial fluid is well tolerated, especially in patients that have limited physical activity. Ecocardiography allows early detection of cardiac tamponade. Development of cardiac tamponade in the evolution of malignancy confers a poor prognosis. The particularity of the case Cardiac tamponade as initial manifestation of lung cancer is a very rare occurrence and only limited data exist in literature. Conclusion Simultaneous presence of ascites, pleural and pericardial effusion should rise the suspicion of malignancy. Abstract P646 Figure.

P646 Cardiac tamponade as initial manifestation of small cell lung carcinoma