Pneumopericardium masquerading as an acute myocardial infarction

Abstract

We describe the case of a 92-year-old gentleman who presented with pneumopericardium mimicking an acute anterior myocardial infarction (MI). The patient presented to the emergency rooms with 2 h of retrosternal chest discomfort radiating to the jaw preceded by syncope. Past history was remarkable for large cell lymphoma involving the oesophagus, which had been in remission for at least 10 years. Physical examination revealed: HR 80 bpm, BP 90/60mmHg and JVP elevated to the angle of the jaw. The rest of the examination was normal. An ECG showed 2 mm ST segment elevation in leads V2–V6. He was transferred to the Cath lab for primary percutaneous coronary intervention (PCI) for presumed acute anterior MI. This revealed minor coronary disease and evidence of pneumopericardium (Movie 1). A pericardial drain was inserted in response to hemodynamic instability. A chest X-ray (Fig. 1A) and CT scan (Fig. 1B) confirmed the diagnosis and showed no other abnormalities including lymphadenopathy. Gastrogaffin swallow and endoscopy were normal. Pericardial fluid culture demonstrated Candida albicans, a known element of oro-gastric flora. He was treated with fluconazole and moxifloxacin and made an uneventful recovery. Given the past history of lymphoma affecting the oesophagus and the presence in the pericardial cavity of a micro-organism found in the oro-gastric tract, it was thought that the cause of the pneumopericardium was a microscopic oesophageal perforation leading to a fistulous connection between the gastrointestinal tract and pericardial cavity.