The patient described here represents a typical case of pulmonary melioidosis with the rare association of pericarditis and pericardial effusion. The patient first presented with persistent high fever, productive cough, and an upper lobe infiltrate which progressed to abscess formation. Electrocardiographic signs of pericarditis and roentgenographic signs compatible with pericardial effusion developed during the initial illness. These resolved following therapy. With recrudescence the patient presented with chest pain. The physical examination, x-ray films, and ECG revealed evidence of pericarditis. The diagnosis was confirmed by pericardiocentesis. The transient lower lobe infiltrate and bilateral pleural effusions developed afterwards, and these resolved with therapy. The spectrum of clinically evident melioidosis ranges from a chronic indolent process'" to an acute septicemic form with a high mortality.i-!' Pulmonary infection in which the pathologic findings are confined to the lungs may clinically be confused with pulmonary tuberculosis. l1 , 1 2 Myocardial melioidosis has been reported as a manifestation of the systemic form of this disease.!" and one case presented as an acute myocardial infarction. I ! Myocardial involvement cannot be excluded in the present case. It seems likely from the course of this patient's illness that the pericarditis and pericardial effusion were secondary to infection with P pseudomallei, even though the organism was never recovered from the pericardial fluid. These complications must, therefore, be added to the manifestations of melioidosis, and the physician should be alerted to this diagnosis in patients with signs and symptoms of pericarditis who have a history of prior residence in southeast Asia. REFERENCES

1 Whitmore A, Krishnaswami CS: An account of the discovery of a hitherto undescribed infective disease occurring among the population of Rangoon. Indian Med Gazette 47:262-267, 1912 2 Stanton AT, Fletcher W: Melioidosis: A new disease of the tropics. Trans Fourth Congress Far East Assoc Trop Med 2:196-198,1921 3 Stanton AT, Fletcher W: Melioidosis: Studies from the Institute of Medical Research, Federated Malay States (No. 21). London, John Bale, Sons and DanieIsson, Ltd, 1932 4 Howe C, Sampath A, Spotnitz M: The Pseudomallei group: A review. J Infect Dis 124:598-606, 1971 5 Kishimoto RA, Brown GL, Blair EB, et al: Melioidosis: Serologic studies on US Army personnel returning from southeast Asia. Milit Med 136:694-698, 1971 6 Clayton AJ, Lisella RS, Martin DO: Melioidosis: A serologic survey in military personnel. Milit Med 138:24-26, 1973 7 Flemma RJ, DiVincenti FC, Dotin LN, et al: Pulmonary melioidosis: A diagnostic dilemma and increasing threat. Ann Thorac Surg 7:491-499, 1969 8 Poe RH, Vassalo CL, Domm BM: Melioidosis: The remarkable imitator. Am Rev Respir Dis 104:427-4.'31, 1971 9 Jackson AE, Moore WL, Sanford JP: Recrudescent melioidosis associated with diabetic ketoacidosis. Arch Intern Med 130:268-271, 1972

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10 Prevatt AI.., Hunt JS: Chronic systemic melioidosis: A note on visual disturbance due to chloramphenicol. Am J Med 23:810-823, 19.57 11 Weber DR, Douglas LE, Brundage WG, et al: Acute varieties of melioidosis occurring in US soldiers in Vietnam. Am J Med 46:234-244, 1969 12 Spotnitz M, Rudnitzky J, Rambaud JJ: Melioidosis pneumonitis: Analysis of nine cases of a benign form of melioidosis. JAMA 2Q-2: 126-130, 1967 13 Piggott JA, Hochholzer L: Human melioidosis: A histopathologic study of acute and chronic melioidosis. Arch Pathol 90:101-111,1970 14 Baumann BB, Morita ET: Systemic melioidosis presenting as myocardial infarct. Ann Intern Med 67: 836-842, 1967

Tumor Emboli Presenting as Pulmonary Hypertension*

A Diagnostic Dilemma James P. Graham, M.D.;'''· Harold H. Rotman, M.D., F.C.C.P.;t and John G. Weg, M.D., F.C.C.P.t

A case of recurrent tumor emboli secondary to choriocarcinoma is described. The patient presented with obvious pulmonary hypertension and was diagnosed and treated as a case of multiple pulmonary embolism. Information which suggested the possibility of tumor emboli was indeed present but recognized only retrospectively.

P

ulmona ry hypertension accompanies a wide variety of disease processes, including diffuse pulmonary parenchymal disease, congenital heart disease, left-sided congestive cardiac failure, and occlusive pulmonary vascular disease. When it is well developed, it may dominate the clinical picture, and it requires a thorough diagnostic evaluation. Given the setting of a young woman in the postpartum period, the diagnostic possibility of pulmonary emboli is uppermost, and pulmonary angiography is probably the single best procedure to employ in the diagnosis. The following case report illustrates how treacherous even the angiogram can be if the history is not paid meticulous attention. CASE REpORT

A 29-year-old woman was admitted to the 'University of Michigan Medical Center, Ann Arbor, on Sept 10, 1973, for the evaluation of chest pain, pulmonary infiltrates, and progressive dyspnea. She had had these symptoms for the preceding four months and has been treated elsewhere for pneumonia with antibiotic therapy without success. Past history revealed that ten months previously, following an "From the Pulmonary Division, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor. Supported in part by U.S. Public Health Service, National Heart and Lung Institute, Division of Lung Diseases Pulmonary Academic Award 1 K07HL70368-03. ""Fellow, Pulmonary Division. t Assistant Professor of Internal Medicine. tProfessor of Internal Medicine. Reprint requests: Dr. Rotman, University Hospital, Ann Arbor 48104

TUMOR EMBOLI PRESENTING AS PUlM·ONARY HYPERTENSION 229

FIGUlIE 1. Posteroanterior chest roentgeno gram showing diffuse bilateral lower lobe infiltrat es, more marked on right. uneventful pregnancy, the pati en t underwent cesarea n section, tubal ligation, and appen dectom y without incide nt. Sub sequ entl y, however, she had noted th e onset of oligomenorrhea with int erm ittent spotti ng, which had per sisted until the time of her cur rent admi ssion . Physica l examina tion revealed a thin tachypn eic woman. Her temperature was 37°C ( 98 .6°F), her puls e rate was 140 beat s per minute, and her resp irati on rate was 40; a waves were seen in the neck, and th ere was a prominent right ventricu lar lift with an S4 gallop. Th e seco nd heart sound was increased , .and the murmur of tri cusp id insufficienc y was detected . Findings from the rem aind er of her physical examination , including pelvic examination by a gyneco logic consultant, were norm al. Arterial blood gas levels breathing room air were pH 7.45; PaO~ , 40 mm ll g; and PaCO ~ , 27 mm Hg. Th e chest x-ra y film is shown in Figure 1. A pu lmonary angiogram was also obtained and is shown in Figur e 2. \ Vith the diagnosis of pulmonary embo lus thu s seeming ly confinned , the pati ent was transfer red to the respiratory inten -

FIGUIIE 3. Dissection of pu lmonary art ery showing occlusion by tum or embolus ( arrows). sive care unit where pa cked cells and hepa rin were administered . Four hours late r, the pa tient suddenly died; at autopsy, she had 2,000 ml of intraperitoneal hemorr hage and tu mor embolus occlud ing the right and left main pulmonary art eries. DISCU SSIO N

T he g ravity of th e cl ini ca l co nd itio n d om in a ted by signs of pulmonary hyperte nsion ! toge th er w it h the "diagnostic" pulmonary angiogram led to th e immed iate in stitution of heparin th e ra p y, a n d it se ems worthwhi le to poin t out that e ve n if the fa ta l outcom e h ad not so quickl y superven ed, th e very ins titution of th e rap y would h av e in evitably delayed making th e diagnosis by defin itive m eans.> This is a ll th e more t ra gic, since in metasta tic choriocarcinoma, th erapy with me tho tr exate may be lifesaving if in stit ut ed at an ea rl y e no u gh ti me . Cl ues to th e true d iagnosis, eg, the prev ious deli ve ry a nd the menstrual irregularity, w ere indeed p res ent but recognized on ly retrospec tiv ely ; and th is case po ints out the dange r o f rel yin g on a tech nica l proced ur e rath e r th a n on a m e ticulous h istory. R E F E RE NCES

FIGURE 2. Pulmonary art eriogram. Note cutoffs to vessels of right middle an d lower lung fie lds.

230 GRAHAM, ROTMAN, WEG

Fowler NO : Chroni c cor pulmona le. Ger iatri cs 22 : 156-171, 1967 2 Hendrickse JP, Willis AJP , Evans KT: Acute dyspnea with trophoblastic tumors. J Ob stet Gynaeco l Br Commonw 72 :376-382, 1965

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