図１〜図５の※は心嚢内の液貯留を示し，図１１で IVC（白矢印：造影早期相だから部分的に造影されている）が大動脈の3倍くらいに腫大しており心タンポナーデである．心嚢液はやや不均一で，図２と図３の▲はextravasationの可能性が高い．図６〜図１７で多発性の不整な造影効果を示す腫瘍性病変があり（△と↑），心臓に近接する図６〜図８の病変△の心嚢内破裂を強く疑う．エコー検査で心タンポナーデと診断され心嚢穿刺を施行したら約900mlの血液が排出され血圧が回復した．2週間後の図A〜図Dで腫瘍性病変は増大し，病変数も増加しており，悪性腫瘍であることを強く示唆し上記所見を裏付ける．心タンポナーデの責任病変と思われる△のTAEを施行したが，2週間後に肝臓の他病変の破裂による大量の腹腔内出血を起こし死亡した．CEA，AFP，PIVKA-2，CA19-9は正常で，CA125だけ40 U/ml（正常：35以下）と軽度上昇していた．肝左葉の膿瘍や腫瘍は心嚢内へ破裂することがあるので注意が必要である．

参考症例（肝膿瘍気管支瘻）：67歳男性．肝細胞癌破裂（図１）に対しTAEを施行した．7週間後（図２）肝細胞癌壊死部に膿瘍を形成したが，経皮経肝的ドレナージを行い（図３）膿瘍は縮小し治癒した．12週間後（図４）膿瘍が再発したので再度経皮経肝的ドレナージを施行した．16週間後（図５：図４から4週間）膿瘍は縮小せず，手術予定であったが，肝膿瘍造影（図A）で気管支が造影され，肝膿瘍気管支瘻が診断された．その2日後から頻回の喀血が出現し，肺炎と呼吸不全を合併し死亡した．

文献考察：種々の肝疾患が心タンポナーデの原因となるが，アメーバ肝膿瘍の報告が最も多い．
１．Jpn J Thorac Cardiovasc Surg. 2005 Apr;53(4):206-9. Cardiac tamponade due to intrapericardial rupture of an amebic liver abscess. Miyauchi T, Takiya H, Sawamura T, Murakami E. Pericardial abscess is rare in healthy individuals, especially the amebic type. We report a case of pericardial abscess and cardiac tamponade due to intrapericardial rupture of an amebic liver abscess. A 31-year old Japanese male complained of fever to a local hospital. A liver mass was discovered in his left hepatic lobe by an abdominal echogram. He was referred to the internal department of our hospital and was treated with quinolone antibiotics. Two weeks after medication, he suddenly complained of epigastralgia and severe orthopnea and was admitted. Abdominal computed tomographic scan showed an enlarged liver mass, and massive pericardial effusion suggested cardiac tamponade. He underwent an emergency subxiphoid partial pericardiectomy under local anesthesia. 1,000 ml of light brownish fluid was removed and his condition improved. Although no ameba was cultivated from the pus, the amebic serological test was positive. Metronidazole was administered and the patient was discharged 31 days after surgery.PMID: 15875556

２．Eur Radiol. 2005 Feb;15(2):234-7. Epub 2004 Oct 16. A tamponade leading to death after radiofrequency ablation of hepatocellular carcinoma. Moumouh A, Hannequin J, Chagneau C, Rayeh F, Jeanny A, Weber-Holtzscherer A, Tasu JP. A case of hemorrhagic cardiac tamponade after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) leading to death is presented. The complication occurred during a procedure performed under general anesthesia with an expandable needle system for a 2-cm HCC sited in the second segment of the liver close to the diaphragm. Thermal damage to the organs surrounding the liver are major complications of liver tumor RFA. For lesions that are adjacent to the cardiac cavities, a discussion of better therapeutic options remains necessary and has to take into account the effectiveness and complication rate of each technique.PMID: 15503044

３．心嚢内穿破をきたした胆汁性肝嚢胞(biloma)の1例　Author：稲田一雄(福岡徳洲会病院 外科), 川元俊二, 白日高歩．Source：日本臨床外科学会雑誌(1345-2843)65巻6号 Page1625-1630(2004.06) Abstract：肝癌治療中に併発した胆汁性肝嚢胞(biloma)が心嚢内穿破をきたしたまれな症例を報告する.症例は60歳,男性.原発性肝細胞癌に対して,肝拡大右葉切除術を施行した.その後,残肝再発に対して,肝動脈塞栓術(TAE)および経皮的マイクロ波凝固療法を併用し,複数回の治療を繰り返し経過した.術後8ヵ月目,閉塞性黄疸と胆管炎が出現した.TAE後の胆管壊死が原因と思われる,左肝管基部狭窄およびその末梢肝管の拡張を認めたため,チューブステント留置にて改善した.その後,外側区にbilomaが出現するも,経過観察していたところ,術後14ヵ月目,突然の前胸部痛および呼吸苦が出現した.画像上,bilomaの心嚢内穿破による心タンポナーデと診断し,心嚢穿刺ドレナージ術を施行し,持続低圧吸引を続け,3日後チューブ抜去が可であった.その後生存中,経皮的膿瘍ドレナージチューブを留置のまま,肝不全による死亡まで術後約20ヵ月間QOLを維持した生存期間を得た(著者抄録)．


４）J Postgrad Med. 2001 Jan-Mar;47(1):37-9. Hepatic hydatid cyst rupturing into sub-diaphragmatic space and pericardial cavity. Ahuja SR, Karande S, Koteyar SR, Kulkarni MV. A ten-year-old male child presented with a large hepatic hydatid cyst which ruptured into the sub-diaphragmatic space and pericardial cavity, giving rise to a pericardial effusion. This communication between the hydatid cyst and the pericardium was documented on computerised tomographic scan of the chest and abdomen. The cyst was aspirated carefully and then enucleated. There was an associated right-sided reactionary pleural effusion. The pericardial effusion and pleural effusion resolved on albendazole therapy and did not require surgical intervention.PMID: 11590291（full text）

５．J Formos Med Assoc. 1998 Mar;97(3):214-6. Amebic liver abscess complicated with cardiac tamponade and mediastinal abscess. Chao TH, Li YH, Tsai LM, Tsai WC, Teng JK, Lin LJ, Chen JH. Amebic pericarditis is an extremely rare complication of liver abscess and an uncommon etiology of sterile pericardial effusion with cardiac tamponade. The association of mediastinal abscess in this clinical setting has not been reported in the literature. Herein, we describe a case of amebic liver abscess complicated with mediastinal abscess and amebic pericarditis with cardiac tamponade. A 44-year-old man was admitted to our hospital because of shortness of breath for the previous 2 days. Cardiac tamponade was diagnosed and emergency pericardiectomy was performed. Chocolate-like pus was found in the pericardial sac and mediastinal space during surgery. Abdominal computed tomography revealed an ill-defined hypodense lesion over the left lobe of the liver, suggesting a liver abscess. Amebic liver abscess and pericarditis were diagnosed on the basis of a high serum titer of amebic antibodies on hemagglutination test. The patient was treated with metronidazole for 2 weeks and discharged in good condition. This case should alert clinicians to the possibility of amebic pericarditis in patients with cardiac tamponade associated with chocolate-like sterile pus in the pericardium and mediastinum. To establish the diagnosis of amebic pericarditis, one should investigate the presence of a liver abscess, a high serum titer of amebic hemagglutination antibodies, and the presence of Entamoeba histolytica trophozoites in the pericardium or pericardial aspirate. PMID: 9549274

６．J Microbiol Immunol Infect. 2002 Sep;35(3):191-4. Morganella morganii causing solitary liver abscess complicated by pyopericardium and left pleural effusion in a nondiabetic patient. Tsai WC, Chang LK. Morganella morganii is a rare cause of solitary liver abscess in Taiwan. The complication of pyopericardium and pleural effusion in nondiabetic patient with solitary liver abscess are also rare. We present a case of a 48-year-old nondiabetic woman who experienced with epigastric discomfort 1 month prior to admission. Chills and fever developed 2 weeks before admission. Physical examination on admission revealed engorgement of the jugular vein over the right neck, precordial friction rubs, and tenderness over the right upper quadrant of abdomen. Chest film showed mild cardiomegaly and left pleural effusion. Computed tomography of the abdomen showed liver abscess, left hepatic lobe, pyopericardium, and left pleural effusion. M. morganii was isolated from 2 sets of blood cultures, one set of hepatic pus culture, and one set of pericardial pus culture. After pigtail drainage of liver abscess, pyopericardium for 12 days, and ceftriaxone intravenous administration for 19 days, the patient was discharged in stable condition.PMID: 12380794

７．J Surg Oncol. 1987 Jan;34(1):13-5. Acute hemorrhagic pericardial effusion complicating angiosarcoma of the liver. Levy I, Mozes M. A 42-year-old woman, with an acute hemorrhagic pericardial effusion, was found to have an angiosarcoma of the liver which caused a massive intraabdominal bleeding due to spontaneous rupture of the liver.PMID: 3492631