Dr. Pepe’s Diploma Casebook 164 – SOLVED

Dear Friends,

Today I will show a new “Meet the examiner case”, with questions and answers similar to a real presentation. You will get more images on Wednesday and the final answer on Friday.

Images belong to a 49-year-old woman with progressive chest pain and dyspnea. She mentions being hit in the chest with a surfboard three weeks ago.

1. Myocardiopathy
2. Pericarditis
3. Myelolipoma
4. Any of the above

What do you see?

Click here to see more images

Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid (A)

Three days days later the patient developed mild symptoms of cardiac tamponade. Portable chest (B) shows increased size of the cardiac silhouette. Enhanced axial CT (C) is shown.
What do you think?

Click here to see the answer

Findings: PA and lateral radiographs (A-B) show what appears to be an enlarged cardiac silhouette. Of the offered options I would think first of pericardial effusion because the pulmonary vessels are small compared to the size of the heart. In cardiomyopathy I would expect engorged pulmonary vessels. Cannot exclude thymolypoma, but I would consider it very unlikely. Probably the best answer is 4. All of the above. And I would recommend a cardiac US because traumatic pericardial effusion is the most likely diagnosis.

Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid. Note the normal thickness of the pericardium (C-D, arrows)

CT also discovered healing fractures of the anterior 4th, 6th and 7th left ribs (E-G, arrows)

After drainage, the heart shadow returned to normal size (H). Three days later the patient developed fever and mild symptoms of cardiac tamponade. Portable chest showed increased size of the cardiac silhouette, despite the presence of a draining catheter (H-I, red arrows).

Enhanced CT demonstrated a moderate amount of pericardial fluid (J-K, arrows) accompanied by bilateral pleural effusions (J, red arrows). The pericardium was surgically explored and cleaned. Staphylococcus Xilosus was grown.

After appropriate antibiotic treatment the symptoms subsided. One month later the chest at discharge appeared normal (L-M).

Final diagnosis: delayed traumatic pericarditis with subsequent infection

Pericardial effusion has many causes, one of them blunt trauma. It is usually associated with other findings: pneumothorax, fractured ribs and lung contusion. Delayed pericardial effusion is a rare manifestation of previous blunt trauma.

Plain film signs of pericardial fluid are unreliable, except for visualization of posterior displacement of epicardial fat in the lateral view, which has high value (epicardial fat sign, Fig. 1). Cardiac ultrasound is the diagnostic technique of choice.

I am showing this case because of the beauty of the initial images and the iatrogenic infectious complication, which muddled the differential diagnosis.

To complete the presentation I am showing a very rare case of cardiac volvulus. It occurred secondary to surgical trauma, after removal of part of the right pericardium (Fig. 2).

I borrowed this case from an American friend a long time ago and am ashamed to confess that I don’t remember who he was. The credit is yours, friend. Many thanks.

Fig. 1. 46-year-old man with liver cirrhosis and pericardial effusion. PA radiograph(A) shows non-specific enlargement of the cardiac silhouette. The lateral view shows posterior displacement of the epicardial fat (B, arrow). The thickened pericardium is visible between the epicardial and mediastinal fat (B, red arrows).

Coronal and sagittal CT confirm the presence of a moderate amount of pericardial fluid (C-D, arrows). Note the displaced epicardial fat in the lateral view (B, red arrow).

Fig 2. 34-year-old woman with Down syndrome with chronic respiratory infections in RLL (A). Bronchoscopy discovered a hemangioma obstructing the intermediary bronchus. At surgery the tumor was adherent to the right pericardium. Pneumonectomy and partial resection of right pericardium were performed.
Post-op portable chest shows moderate prominence of the right heart border (B, arrow).

Six hours after the intervention the patient started to deteriorate and went into shock. Portable radiograph shows displacement of the cardiac silhouette to the right (C, arrow) and complete herniation of the heart into the right hemithorax twelve hours later. (D, arrow). A second intervention confirmed a cardiac volvulus that was corrected with a pericardial patch.

Follow Dr. Pepe’s advice:

1. Delayed pericarditis after blunt trauma is rare. Should be considered when the cardiac silhouette enlarges following blunt chest trauma

2. Echocardiography is the diagnostic method of choice for diagnosing pericardial fluid

3. Plain film signs of pericardial effusion are unreliable, except for visible displaced epicardial fat in the lateral radiograph

21 thoughts on “Dr. Pepe’s Diploma Casebook 164 – SOLVED

  1. Acute angle between the heart border and the disphragm and also the relevant patient’s history -> pericarditis. There might also be a small pleural effusion on the left side.

      1. Update
        I see a pneumopericardium (A) and then pericardial effusion again ( B ) .
        CT confirms the findings- pericardial air-fluid levels and also bilateral pleural effusions.
        I think the possible cause of pericardial effusion might be a fistula ( pericardial-esophageal fistula ), given the posttraumatic context.
        ( at least, his was the first thing that came into my mind the moment I saw the aditional images)
        Impatiently waiting for the answers! Have a nice day!

  2. Good morning Dr!!!

    On the PA it seems to be a cardiomegaly but on the lateral view there is an obliteration of the retrocardiac space with double contour, so can it be a false cardiomegaly because of an lower anterior mediastinal mass?

  3. If the patient was hit with surfboard fractures should be excluded – I could not find any visible signs of them.

    As lingula is obscured because of increased heart, still I suggest some hyperdensity in that region.

  4. Cardiac shadow is prominent….Pericardial effusion or mediastinal hematoma in view of history of trauma

  5. At first sight cardiac silhouette seems enlarged and according to past trauma I would suggest pericardial effusion but looking more closely: subcarinal angle is quite sharp, no pericardial lucent lines (Oreo sign), no signs of pulmonary congestion and double retrocardiac silhouette. I would strongly consider mediastinal mass, combining the age & dyspnea: thymoma with myasthenia gravis.

  6. hemopericardium leading to cardiac tamponade and bilateral pleural effusion
    advise ct angio of thoracic aorta to rule out any dissection with rupture into pericardium

  7. …Carissimo PROF….in TC si vede l’esito di una frattura sterno-costale, con il lembo costale introflesso…S.del volet costale, lembo mobile….pericardite essudativa e versamento pleurico…

  8. I want to be here so insane and dare to suggest traumatic pericardial fat necrosis, i see on CT subpericardial fat-containing ovoid area, i see also calcified pericardium with pleural and pericardial effusion, contrictive pericarditis ?

    1. You went out in a limb there! But I like your imaginative diagnosis.
      I have seen a few cases of pericardial fat necrosis and the effusion was always scarce, unlike this case.

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