Massive Pericardial Effusion in a 14-Year-Old Girl with Mild Fatigue and Neck Pain

Round 1

Reviewer 1 Report

While the article might be potentially interesting, there are different issues about it:

1. The language needs to be reviewed extensively. The manuscript doesn't read well and, now and then, it is hard to understand.
2. This report doesn't provide any additional information to what it is already in literature. We know that these patients present with a variety of symptoms and that the clinical presentation depends on the rate of accumulation of fluid. We also know that a high percentage might be idiopathic, and that more than 30% of the drained pericardial effusions don't recur. The authors mentioned that this patient is at follow up, one piece of information a reader might be interested in knowing is when the patient presented (at first) and how far it was from his/her last follow up.
3. The 'novelty' of using point of care echocardiography is not investigated enough. The authors mentioned it very briefly in the case presentation and then concluded it can be used by non-radiologist to confirm diagnosis.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

A very-well presented case of pericardial effusion in a 14yo adolescent. Cases like this should be presented and published as they keep the clinical suspicion high, especially in cases with unclear symptoms. Good structure and scientific soundness. 

I wish to ask the authors if they tested for malignancy; this information should be included in the manuscript. 

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report

The case presented here was a 14-year-old girl with massive pericardial effusion, which improved after pericardiocentesis to avoid cardiac tamponade. Although the serology did not lead to a definitive diagnosis, the clinical course of this case is very interesting. I would like to make a few comments.

1. Line 39: Please clarify the details about the neck pain. The reader cannot identify whether it is lymphadenopathy or skeletal muscle pain (pain on movement). If it is lymphadenopathy, an airway infection is suggested.

Table 1: Please reverse the use of commas and periods, respectively. Also, if thyroid function is evaluated, please add it.

Line 66: Beck's triad, which typically consists of jugular venous distension, hypotension, and reduced heart sounds, is well known for differentiating cardiac tamponade, but its sensitivity is not very high. An pulsus paradoxus is defined as a systolic blood pressure drop of 10 mmHg or more on inspiration, and there are reports that the specificity is as high as 70% when an pulsus paradoxus is present (JAMA. 2007;297(16):1810-8.). Even if blood pressure cannot be measured continuously, it can be evaluated by echocardiography, and if there is an increase in tricuspid valve inflow or a decrease in mitral valve inflow on inspiration, the possibility of a pulsus paradoxus increases. Please describe the presence or absence of these assessments in this case.

4. Line 74: Were these items measured in pericardial fluid or blood?

5. Line 78: Were these tests done separately from the tests on line 43?

6. I have experienced a case of systemic lupus erythematosus with pericardial fluid. Please clarify the antibodies you evaluated (if any, scleroderma and Sjogren's syndrome are in the differential besides rheumatoid arthritis).

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

I believe the authors have responded properly to the reviewers' suggestions and revised the manuscript.

Please correct some minor points.

Line 79. The authors mentioned pain, did this refer to neck pain? If the symptoms improved with pericardial fluid drainage, is it possible that this pain originated from hemodynamic disturbances?

Line 87. A negative result for autoantibodies does not negate an autoimmune disease. Please also add that the patient did not have any physical findings suggestive of each autoimmune disease.

Line 88. Please clarify the details of the tuberculosis test.

Line 118. The progression to pericardial tamponade is related not only to the speed of pericardial effusion but also to the extensibility of the pericardium (Ref. 7). In this case, due to the young age, the connective tissue, including the pericardium, as well as the soft tissue, such as the lungs, were highly variable, which may have helped alleviate the symptoms despite the large amount of pericardial effusion.