European Journal of Cardiovascular Medicine

Pericardial effusions can be life-threatening medical emergencies. Pericardial effusions can occur secondary to pericarditis, infections, post pericardiotomy syndrome, rheumatologic causes, malignancy, bone marrow transplant, and additional causes (Vakamudi, 2017). They can develop acutely or chronically, and if left untreated, become life-threatening. The primary treatments have been anti-inflammatory agents, including ibuprofen and steroids, treating the underlying cause, and if required, invasive pericardiocentesis. Unfortunately, depending on the underlying cause, pericardial effusions can reform, requiring repeated treatments. However, if pericardial effusions continue to recur, an invasive surgical pericardial window becomes necessary.

Colchicine has been an approved therapy for pericarditis in adults (Imazio, 2017). Its usage in pediatrics is limited and extrapolated from adult literature (Alabed, 2016). We report a case of a patient with a history of Acute Myeloblastic Leukemia (AML), status post a second bone marrow transplant (BMT), with recurrent pericardial effusions treated with Colchicine.

Our patient, SG, was diagnosed with AML with bilateral ocular involvement at 4 years of age. His initial treatments (chemotherapy) were prior to coming to our institution, in an international setting. He had relapsed following initial treatment and required reinduction therapy with chemotherapy and radiation (for ocular disease) prior to undergoing his first bone marrow transplant on June 21, 2024. After developing graft failure post first transplant, he underwent a second bone marrow transplant on August 14, 2024. His treatment at our institution included chemotherapies (Asparaginase, Busulfan, Cyclophosphamide, Cytarabine, Fludarabine, Mesna, Methotrexate, Methylprednisolone, rabbit anti-thymocyte globulin, and prednisone), bilateral orbital radiation (905cGY), and total body irradiation (300cGY).

He first developed a pericardial effusion on August 26, 2024, which grew to a large effusion by September 5, 2024. Due to thrombocytopenia, he was not a candidate for non-steroidal anti-inflammatory agents (NSAIDs),and thus underwent a pericardiocentesis. His pericardiocentesis catheter was removed on September 9, 2024. By October 2, 2024, his pericardial effusion had reaccumulated to a moderate to large effusion. Due to a diagnosis of graft-versus-host-disease (GVHD), he continued the steroids he was already receiving as treatment for this indication. In addition, Eculizumab was initiated for concerns of transplant-associated thrombotic microangiopathy (TA-TMA). By November 26, 2024, the pericardial effusion was again large with tachycardia, requiring a second

 pericardiocentesis. The drain was removed on November 28, 2024. On December 19, 2024, yet again, his pericardial effusion was large, despite receiving steroids and treatment for TA-TMA. The decision was made to initiate Colchicine, with the plans to continue in combination with steroids for 3-6 months, until clinical improvement was visualized. He started low dose Colchicine on 12/26/24 secondary to cross reactivity with his other medications and renal safety. The dose was subsequently increased on January 8, 2025, secondary to no significant improvement in the pericardial effusion. By January 22, 2025, the effusion started to decrease in size. However, due to concern for acute kidney injury, the Colchicine dose was decreased to a lower dose. Despite the dose decrease of Colchicine, SG’s pericardial effusion continues to decrease in size on serial echocardiograms, with the last one being small to moderate on April 21, 2025.

Although we have not trialed our patient off the Colchicine yet, we find it important to highlight the improvement seen in this case thus far to further increase knowledge and potential medical management options for pediatric bone marrow transplant patients with pericardial effusions. Pericardial effusion with or without polyserositis is a strongly associated complication of TA-TMA in the post-BMT setting, with reported incidence as high as 52% in this sub-population of BMT patients (Jodele et al., 2015).

This is the first report on the use of Colchicine in a child after bone marrow transplant for pericardial effusions. There have been studies reporting the use of Colchicine for recurrent pericarditis in adults. However, there have been limited reports and case series on the use of Colchicine in pediatrics, let alone after bone marrow transplants.

Despite the acute kidney injury (AKI) (that has resolved), Colchicine has been well tolerated by SG over the past 4 months. There were no reports of other side effects, including GI symptoms. In addition, we have been able to avoid a third invasive pericardiocentesis (or even a surgical pericardial window) for at least five months, and hopefully longer. Prior to the start of the Colchicine, SG was requiring a pericardiocentesis every two months.

1.       Alabed S, Pérez-Gaxiola G, Burls A. Colchicine for children with pericarditis: systematic review of clinical studies. Arch Dis Child. 2016 Oct;101(10):953-6. doi: 10.1136/archdischild-2015-310287. Epub 2016 Apr 15. PMID: 27083755.

2.       Imazio M. Colchicine for pericarditis. Trends Cardiovasc Med. 2015 Feb;25(2):129-36. doi: 10.1016/j.tcm.2014.09.011. Epub 2014 Oct 2. PMID: 25454379.

3.       Jodele S, Laskin BL, Dandoy CE, et al. A new paradigm: Diagnosis and management of HSCT-associated thrombotic microangiopathy as multi-system endothelial injury. Blood Rev. 2015;29(3):191-204. doi:10.1016/j.blre.2014.11.001

4.      Vakamudi S, Ho N, Cremer PC. Pericardial Effusions: Causes, Diagnosis, and Management. Prog Cardiovasc Dis. 2017 Jan-Feb;59(4):380-388. doi: 10.1016/j.pcad.2016.12.009. Epub 2017 Jan 4. PMID: 28062268.