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A 66 year old man was admitted because of monosymptomatic fever. Acute laboratory findings indicated severe infection and ECG showed low voltage and atrial fibrillation with a heart rate of 116 beats/min. A chest radiograph (right) showed pneumopericardium, making transthoracic echocardiography (TTE) impossible. Transoesophageal echocardiography (TOE), however, disclosed normal heart function but echodense material indicating pus in the pericardium behind the heart. Surgery and endoscopy showed pneumopyopericardium caused by a gastric ulcer, penetrating through the diaphragm to the pericardium. The patient was treated successfully with pericardial drainage, prolonged antibiotic therapy, and surgical resection of the gastropericardial fistula. Gastrointestinal fistula's are well established causes of pneumo- and pyopericardium.
Chest radiography is an excellent imaging technique for establishing the diagnosis of pneumopericardium but is of limited value in the analysis of a potential cardiac component of shock. In such cases, where air obstructs the window of TTE, TOE may be useful.