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Chest pain, dyspnoea and hypotension in a 61-year-old woman
  1. Waldemar Myszka1,2,
  2. Agata Nowak1,2
  1. 1Department of Internal Medicine, Cardiology and Hypertension, HCP Medical Center in Poznan, Poznan, Poland
  2. 2Department of Clinical Biochemistry and Laboratory Medicine, Poznan University of Medical Sciences, Poznan, Poland
  1. Correspondence to Dr Waldemar Myszka, Department of Clinical Biochemistry and Laboratory Medicine, Poznan University of Medical Sciences, 6 Grunwaldzka Str. Poznan 60-780, Poland; wmyszka{at}ump.edu.pl

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From the question on page 960

Clinical introduction

A 61-year-old women presented to the emergency room with acute onset dyspnoea, palpitations and severe weakness. These symptoms followed a non-strenuous physical effort a few hours before admission. She reported an unintentional 10 kg weight loss over the course of a 6-week period. Her past medical history was significant for breast cancer treated successfully with chemotherapy and mastectomy 10 years prior to presentation.

On admission, the patient was in severe clinical distress, visibly cachectic, tachycardic (heart rate 130 bpm) and hypotensive (blood pressure 80/60 mm Hg). Heart and lung auscultation revealed no abnormalities. There was pain on palpation of the epigastrium. The liver was palpable below the right costal arch. Laboratory tests revealed elevated C-reactive protein of 73.7 mg/L (normal <3 mg/L) and D-Dimers of 3648 ng/mL (normal <500 ng/mL). Serial troponins were within normal range. Arterial blood gas analysis showed no marked abnormalities. Blood counts demonstrated anaemia (haemoglobin 6.86 mmol/L) and leucocytosis (white blood cells 13.2 G/L). ECG showed sinus tachycardia. A posteroanterior chest X-ray obtained on admission is shown in figure 1.

Figure 1

Posteroanterior chest X-ray.

Question

What is the abnormality seen in this patient's chest X-ray?

  1. Pulmonary oedema

  2. Pneumopericardium

  3. Effusive pericarditis

  4. Pulmonary embolism

  5. Pneumothorax

For the answer see page 987

From the question on page 960

Answer: B

The chest X-ray demonstrates the presence of air in the pericardial sac, a case of pneumopericardium. Pulmonary oedema (answer A) on chest X-ray would demonstrate ‘bat wing’ or ‘butterfly wing’ pulmonary opacities. Pericarditis with pericardial effusion (answer C) would show the so called ‘water bottle sign’, in which the cardiac silhouette is enlarged and assumes the shape of a flask or water bottle. Pulmonary infarction, often resulting from embolism (answer D), would cause a triangular shadow with its base close to visceral pleura. Pneumothorax (answer E) would show air in the pleural cavity with characteristic pleural reflection. None of those aforementioned abnormalities are present in the picture.

Pneumopericardium is a very rare condition defined as a presence of air in the pericardial sac. It was first described by Bricketeau in 1844. The most common causes of pneumopericardium include: traumatic injury, complications due to diagnostic and therapeutic procedures (laparoscopy, bone marrow aspiration, tracheostomy, thoracocenthesis, thoracotomy, endotracheal intubation, pacemaker implantation, ablation), barotrauma (cough, exacerbation of asthma), infection or fistula to pericardium (oesophagus cancer, gastric cancer, pulmonary cancer, perforation of gastric ulcer, achalasia, pulmonary emphysema, pulmonary aspergillosis and aspiration of foreign body.1–3

Patient's chest X-ray, laboratory findings and poor clinical condition prompted a referral for CT of the chest, abdomen and pelvis. The imaging revealed pneumopericardium with air cavity thickness reaching approximately 15 mm. In the area of oesophageal hiatus of diaphragm, there was a mass retracting the distal portion of oesophagus as well as an infiltrated and thickened left diaphragmatic leaf. In the subphrenic area, there was extensive infiltration involving the subcardial area of the gastric wall and several polycystic masses lying along the splanchnic surface of the left hepatic lobe. The thick-walled gastric air cavity was in continuum with the infiltrated pericardial sac (figure 2).

Figure 2

CT scan of the chest showing a thick layer of air in the pericardial sac and a continuum of the air cavity between the pericardial sac and stomach.

The treatment of pneumopericardium is puncture and drainage of the pericardial sac.1 In patients who are haemodynamically stable, oxygen therapy and symptomatic treatment are preferred. In our patient, immediate needle aspiration was performed resulting in improvement of her haemodynamic parameters (correcting the cardiac tamponade due to pneumopericardium). Unfortunately, despite critical care and management, the patient died on the fifth day of hospitalisation. Autopsy confirmed gastric adenocarcinoma with the infiltration of diaphragm and pericardial sac, providing explanation for patient's pneumopericardium.

References

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Footnotes

  • Contributors Both authors have contributed in collecting data and preparing the manuscript for review.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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