SPONTANEOUS PNEUMOPERICARDIUM: A CASE REPORT OF AN UNUSUAL AND A RARE PRESENTATION

Abstract

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous pneumopericardium is defined as the presence of free air in the pericardial sac without apparent precipitating cause. It is more common in young adults without pre-existing pulmonary disease (1). Although often asymptomatic, it can cause chest pain and shortness of breath. Progression of this condition into Tamponade can be life-threatening. We describe the case of a 21-year-old female who presented with shortness of breath and was incidentally found to have pneumopericardium. CASE PRESENTATION: A 21-year-old female with obstructive sleep apnea and asthma presented with cough with blood-tinged sputum production and shortness of breath for 3 days. On examination, she was tachypneic, had muffled heart sounds and bilateral wheezes. A chest x-ray showed pneumomediastinum along with pneumopericardium (figure 1). EKG without evidence of ischemic changes or tamponade. A CT scan of the chest was done that showed pneumopericardium with pneumomediastinum and extensive soft tissue gas insulating to the deep fascial planes of the neck and upper chest (figure 2 & 3). There were no signs of esophageal rupture. She was initially treated with broad-spectrum antibiotics and intravenous steroids. Antibiotics were later stopped as no infectious etiology was found. The patient remained hemodynamically stable throughout the hospital course. Repeated chest x-ray imaging on day 2 showed improving pneumopericardium and pneumomediastinum. She was eventually discharged from hospital and imaging during her office follow-up showed complete resolution of the pneumopericardium and pneumomediastinum (figure 4). DISCUSSION: Spontaneous pneumopericardium is rare. Common causes include trauma- secondary to perforation of the pericardium, infection by a gas-forming organism, viscus perforation such as the esophagus, stomach, liver abscess, iatrogenic. ‘’Macklin effect’’ describes the mechanism of air collection in the mediastinum. The increased pressure gradient between the alveoli and the interstitial space leads to the rupture of the alveolar structure resulting in air leakage. A tinkling sound superimposed over a succession splash can be heard, as a result, called “Bruit de Moulin”, which is French for “Millwheel murmur”.(2) Symptoms include dyspnea, precordial chest discomfort, upper abdominal pain or syncope. Physical examination may be absent or may include subcutaneous emphysema, Hamman sign, Millwheel murmur or Beck’s triad (if Tamponade develops). CONCLUSIONS: All the patients should be admitted to the hospital and should be monitored. The initial therapy should be targeted at underlying disease processes. Supplemental oxygen will enhance the reabsorption of the free air by increasing the gradient of nitrogen between the alveoli and the tissues. Symptoms typically resolve within 24-48 hours and follow up CXR should be done to look at progression/resolution or for the complications. (1) Reference #1: Young-Jung Lee, M.D., Seung-Won Jin, M.D., Sung-Hee Jang, M.D., Yi-Sun Jang, M.D., Eun-Kyoung Lee, M.D., Yong-Joo Kim, M.D., Man-Young Lee, M.D., Jun-Chul Park, M.D., Tai-Ho Rho, M.D., Jae-Hyung Kim, M.D., Soon-Jo Hong, M.D., and Kyu-Bo Choi, M.D. A Case of Spontaneous Pneumomediastinum and Pneumopericardium in a Young Adult. Korean J Intern Med. 2001 Sep; 16(3): 205–209. Reference #2: R S Baum, T G Welch, and A L Bryson. Spontaneous pneumopericardium. West J Med. 1976 Aug; 125(2): 154–156. DISCLOSURES: No relevant relationships by NIRAJAN ADHIKARI, source=Web Response No relevant relationships by Subash Ghimire, source=Web Response