Pneumopericardium following severe thoracic trauma

BACKGROUND

Traumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication.  Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury.

METHODS

We conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management.

RESULTS

Over a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18-77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC.

CONCLUSIONS

Traumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.

Computed Tomography-Guided Pericardiocentesis: A Practical Guide

PURPOSE OF REVIEW

The purpose of this article is to serve as a practical guide to computed tomography (CT)-guided pericardiocentesis and to discuss the role of this approach in current clinical practice. An overview of indications, technique, advantages, and limitations specific to CT-guided pericardiocentesis will be provided. The reader will have an enhanced understanding of the use of this imaging modality to guide pericardial drainage.

RECENT FINDINGS

Use of CT guidance to drain the pericardial space is safe, especially when adequate echocardiographic evaluation is precluded and when echocardiography-guided pericardiocentesis is deemed unsafe and or not feasible. Our review and experience indicate that CT-guided pericardiocentesis is technically successful in more than 94% of patients, with a low risk (<1%) of significant complications. CT-guided pericardiocentesis is therefore a viable alternative when echocardiographic guidance is insufficient and can obviate the need for surgery in most patients.

Case Series on Barotrauma in COVID-19 Infection Patients

As COVID-19 emerged in the world, there was a high prevalence of intubation and intensive care admissions. Many cases of barotrauma were reported in those patients. This condition is caused by alveoli rupture, which causes the air to enter the surrounding extra-alveolar spaces. It mainly happens in intubated patients. Here, we report 14 cases of barotrauma in COVID-19 patients, which appeared either spontaneously or after receiving non-invasive ventilation, some of the patients presented initially with mild-moderate forms of the disease in terms of severity. Developing barotrauma causes a management challenge in COVID-19 patients, where the patients might require invasive mechanical ventilation afterwards, which is a difficult situation. Lung protective measures should be used to reduce the risk of barotrauma in all patients as it is associated with increased mortality.

Marked hemopneumopericardium in a patient with rectal cancer with distant metastasis: a case report

INTRODUCTION

Hemopneumopericardium defines a condition of combined pathology of weakened, dense blood content (hemopericardium) and air (pneumopericardium) in the pericardial cavity with an air fluid level. It is a rare disease, with only one such case reported in the literature. In this case report, we assessed a patient rectal cancer in addition to hemopneumopericardium, dyspnea, and chest pain.

CLINICAL CASE REPORT

A 47-year-old Arab woman previously diagnosed with rectal cancer metastasized to bones, lymph nodes, and lungs post-Hartmann procedure reported to the emergency department complaining of worsening dyspnea for 2 weeks, more significantly in the supine position. A productive cough with yellowish sputum characterized this; however, there was no pertinent family or psychological history. Examination of the respiratory system revealed dullness on the left side associated with decreased breath sound. The chest radiograph also revealed marked hydro-pneumopericardium. Spiral computed tomography angiography of pulmonary arteries demonstrated pericardial effusion with the air fluid level at pericardial space, implying hydro-pneumopericardium.

CLINICAL CONCLUSION

A successful pericardiocentesis was performed, in which 180 cc of blood-filled pericardial fluid was drained, suggesting the presence of hemopneumopericardium. Hemopneumopericardium has multiple etiologies, yet critical intervention is restricted in patients with cardiac tamponade. Hence, pericardiocentesis could be a definitive treatment.

The effects of pneumopericardium during epicardial catheter ablation after dry pericardiocentesis on patients with ventricular arrhythmia

BACKGROUND

Pneumopericardium is a rare complication of epicardial ablation after dry pericardiocentesis to treat ventricular arrhythmia (VA); its exact clinical effects on patients are still unclear. The purpose of this study was to evaluate the clinical effects of pneumopericardium during epicardial ablation on patients with VA.

METHODS

Patients with VA who underwent epicardial catheter ablation under local anesthesia at West China Hospital of Sichuan University from August 2012 to January 2022 were enrolled in this study. The incidence of pneumopericardium was investigated. The occurrence of major adverse cardiovascular events (MACEs) was evaluated 1 year after the operation.

RESULTS

A total of 86 VA patients were included in the study. Twenty-two cases had pneumopericardium, with an incidence rate of 25.6%, and 12 (54.55%) patients complained of dyspnea during the procedure with an average occurrence time of 5.4 ± 3.2 min after pericardiocentesis. The blood pressure (BP) decreased significantly, with the mean BP dropping from 119.8/73.2 to 103.5/64.9 mmHg (p < 0.001). None of the cases progressed to tension pneumopericardium. Postoperative follow-up with a median period of 411 days showed that the incidence rate of major adverse cardiovascular events (MACEs), including the composite endpoints of all-cause death, rehospitalization for heart failure, and tachyarrhythmia events, was 36.4% (n = 8) in the pneumopericardium group and 35.5% (n = 23) in the non-pneumopericardium group. The Kaplan-Meier survival analysis showed that there was no statistically significant difference in the incidence of MACEs between the two groups (p = 0.28).

CONCLUSIONS

The incidence of pneumopericardium during epicardial ablation was relatively high. However, if recognized early and managed properly, it is unlikely to progress to tension pneumopericardium. The occurrence of pneumopericardium during the procedure may not significantly affect the long-term prognosis of patients.

Lung Cancer-Related Pneumopericardium

N/a.

Pulmonary barotrauma in COVID-19: A systematic review and meta-analysis

BACKGROUND

An ever-increasing number of studies have reported an increased incidence of spontaneous pulmonary barotrauma such as pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients with COVID-19. We conducted this systematic review and meta-analysis to assess the value and significance of the available data.

METHODS

A thorough systematic search was conducted to identify studies of barotrauma in hospitalized patients with COVID-19. Data analysis of case reports was done using a statistical package for the social sciences (SPSS) version 22, and meta-analysis was performed using CMA-3.

RESULTS

We identified a total of 4488 studies after thorough database searching.118 case reports and series, and 15 observational studies were included in the qualitative analysis. Fifteen studies were included in the quantitative analysis. The observational studies reported barotrauma in 4.2% (2.4-7.3%) among hospitalized patients; 15.6% (11-21.8%) among critically ill patients; and 18.4% (13-25.3%) in patients receiving invasive mechanical ventilation, showing a linear relationship of barotrauma with the severity of the disease. In addition, barotrauma was associated with a longer length of hospital stay, more extended ICU stay, and higher in-hospital mortality. Also, a slightly higher odds of barotrauma was seen in COVID-19 ARDS compared with non-COVID-19 ARDS.

CONCLUSION

COVID-19 pneumonia is associated with a higher incidence of barotrauma. It presents unique challenges for invasive and non-invasive ventilation management. Further studies are required to unravel the underlying pathophysiology and develop safer management strategies.

Pneumomediastinum, pneumopericardium and subcutaneous emphysema following acute lymphoblastic leukemia and chemotherapy: A case report

Background:

Pneumomediastinum and subcutaneous emphysema are mostly detected in non-malignant conditions such as certain infections, thoracic surgeries, and trauma. Although this condition is asymptomatic in most cases, sometimes it could be symptomatic and may even be lethal in some patients.

Case Presentation:

This letter reports a 9-year-old girl with acute lymphoblastic leukemia (ALL) on chemotherapy who developed pneumothorax with the clinical feature of respiratory distress for that a chest tube was inserted immediately. Following the insertion, pneumomediastinum and pneumopericardium developed in the patient. As the next step, a pericardium window was inserted by an expert heart surgeon. During these procedures, all the evaluations for any bacterial or fungal infection were negative. Unfortunately, the patient expired before any further complementary evaluations and it was not clear that the mentioned situation was a result of chemotherapy or ALL.

Conclusion:

Although pneumomediastinum and subcutaneous emphysema are rare in patients with ALL, authors strongly suggest clinicians consider them in any similar patients presenting respiratory signs/symptoms for faster onset of action.

Simultaneous spontaneous pneumomediastinum and pneumopericardium in a critically ill patient with COVID-19

Case in the paper is of a 24-year-old woman presenting to Baqiyatallah hospital, Tehran, Iran with the occasional fever, weakness, myalgia, fatigue, body aches, and headache who was diagnosed with Coronavirus disease-19 (COVID-19) PCR test. Chest computed tomography (CT) showed spontaneous pneumomediastinum (SPM) and pneumopericardium (SPP). Here, we described SPM, and SPP in a patient with COVID-19, presenting a severe course of the disease.

Finding the bubble: atypical and unusual extrapulmonary air in the chest

OBJECTIVE

To describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients.

CONCLUSION

In this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).

Isolated pneumopericardium; An extremely rare complication following active resuscitation in a term neonate

BACKGROUND

Pneumopericardium, presence of air in pericardial cavity, is rare entity with potentially severe complications and mortality. In the neonatal period, it is associated with prematurity, low birth weight, and assisted ventilation, but in full term neonates its occurrence after resuscitation is exceedingly rare.

CASE REPORT

Our patient was a 2-day old full term neonate who developed respiratory distress following active resuscitation which was carried out at the time of birth in lieu of perinatal asphyxia. He was immediately put on mechanical ventilatory support. Chest x-ray showed a "halo sign"- rim of air completely surrounding the heart, and echocardiography confirmed pneumopericardium with cardiac tamponade. Pericardiocentesis was performed as a life saving measure.

CONCLUSION

He was successfully discharged on the tenth day following sheath removal, and is doing fine on follow up.

Post-traumatic compressive pneumopericardium with spontaneous ventilation: Case report

Pneumopericardium is a rare complication of a blunt thoracic trauma. It is defined as the presence of air in the pericardial sac. There are just a few cases described in the literature.

This article brings pneumopericardium to light, reinforcing the importance of considering it within the blunt chest trauma and remarking its management with a careful monitoring for the patients whose stable or even asymptomatic with spontaneous ventilation because of the risk of tension pneumopericardium and cardiac arrest.

Diagnosis is often difficult, and it can be life-threatening by the occurrence of gas tamponade.

We report the case of a 48 years old patient victim of a severe traumatism with pneumothorax and pneumopericardium; he was stable with spontaneous ventilation.

Gastropericardial fistula induced acute purulent pericarditis

Gastropericardial fistula is a rare but lethal condition. Several etiologies have been reported, including previous gastric or esophageal surgery, malignancy, trauma, infection, and ulcer perforation. Typical symptoms included chest pain, epigastric pain, fever and dyspnea. Gastropericardial fistula can lead to serious complications, including cardiac tamponade, sepsis, hemodynamic compromise and death. Therefore, early diagnosis and timely management are important for physicians to prevent from catastrophic complications. Here, we present a case of a man who presented with acute purulent pericarditis secondary to a gastropericardial fistula to highlight the pathogenesis and suggest therapeutic strategies.

Symptomatic pneumopericardium - A rare complication following retroperitoneal laparoscopic nephrectomy: A case report

INTRODUCTION AND IMPORTANCE

Pneumopericardium is collection of gas in pericardial space. Retrospective reviews have described pneumopericardium as a complication of laparoscopic surgery, however, without any symptoms. By this report, we present a case who developed acute cardiopulmonary symptoms after retroperitoneal laparoscopic radical nephrectomy because of pneumopericardium.

CASE PRESENTATION

A 40-year-old Vietnamese woman was admitted due to left flank pain. She was diagnosed with left dysfunctional hydronephrosis and right urolithiasis. Six hours post-operation of an elective retroperitoneal laparoscopic radical nephrectomy, she suddenly developed severe substernal chest pain and dyspnea. Evaluations for acute myocardial infarction and pulmonary embolism were immediately ordered with no abnormality. However, computed tomography scan of the chest showed pneumopericardium, pneumomediastinum, subcutaneous emphysema, gas collection in sub-peritoneal space and next to the aortic arch. She was then closely monitored and effectively managed by conservative treatments.

CLINICAL DISCUSSION

Pneumopericardium is a rare complication of laparoscopy and mainly detected by radiographical measures incidentally. Several case studies reported symptomatic pneumopericardium, as in our presenting case. Some factors might contribute to the mechanism of our case that include retroperitoneal approach, thoroughly dissection the renal helium area and long-lasting operation. Post-operative collection of carbon dioxide is well self-limited; therefore, conservative treatments are efficient for stable cases.

CONCLUSION

Pneumopericardium following laparoscopy is uncommon, and mostly subclinical. However, it can manifest as acute cardiopulmonary symptoms and signs that require carefully evaluation. The presence of gas in pericardial space is a negative prognosis factor itself; consequently, clinicians should be aware of when managing pneumopericardium subsequent to laparoscopic procedures.

Effusive-constrictive pericarditis secondary to pneumopericardium associated with gastropericardial fistula

A 66-year-old man with a history of gastric pull-up reconstruction for oesophageal cancer was hospitalized because of prolonged chest pain. Chest X-ray demonstrated pneumopericardium. Computed tomography revealed ulceration and abscess in the gastric conduit adjacent to the heart, suggesting gastropericardial fistula. As the patient did not show tamponade physiology, he was conservatively treated with antibiotics. The pneumopericardium diminished; however, he developed effusive-constrictive pericarditis with overt heart failure symptoms. Because pericardiocentesis failed to relieve the symptoms, pericardiectomy was performed. Intraoperative exploration revealed remarkably thickened pericardium and epicardium constituting multiple layers with purulent effusion. Epicardiectomy as well as pericardiectomy were required to achieve the effective reduction of central venous pressure. Perforation of the gastric conduit into the pericardial cavity was identified and repaired. Histopathology demonstrated thickened pericardium composed of hyalinized stroma, collagenous bundles, and infiltration of inflammatory cells. Streptococcus anginosus and Candida tropicalis were identified by culture of the resected tissue.

Pneumopericardium, pneumomediastinum and air travel: A case report in a patient with Gardner syndrome

Onboard aircraft medical emergencies are on the rise as commercial air traffic is increasing. However, thoracic injury secondary to air travel is extremely rare and, most reported injuries are cases of pneumothoraces. Spontaneous pneumomediastinum and pneumopericardium have been barely reported in the medical literature as a complication of air travel. We are reporting a case of spontaneous pneumopericardium and pneumomediastinum in a patient with Gardner's Syndrome after a flight from Central America to New York City. The patient presented with chest discomfort. He was managed conservatively with oxygen therapy as he was hemodynamically stable throughout his stay in the hospital. A thorough work up in hospital including and esophagogram and a CT scan of the chest were none revealing of the cause. However, the patient was noted to have metastatic rectal cancer with lung involvement. The patient was discharged with instructions to avoid air travel.

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Air travel emergencies are on the rise with the increasing air traffic.

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Pneumomedisatinum and Pneumopericardium post air travel are rare but reported complications.

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Treatment consists of treating the underlying cause. Management Guidelines are absent to date.

Iatrogenic pneumopericardium after tube thoracostomy: A case report

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Iatrogenic pneumopericardium following tube thoracostomy is exceedingly rare.

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Delayed or missed diagnosis of iatrogenic pneumopericardium can be fatal.

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Infants tend to develop tension pneumopericardium urging surgical intervention.

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Iatrogenic pneumopericardium in infants can be managed conservatively with caution.

Introduction

Pneumopericardium, the presence of air within the pericardial space, is a rare occurrence which usually follows positive pressure ventilation in infants, or blunt and penetrating thoracoabdominal injuries in adults. The occurrence of iatrogenic pneumopericardium following tube thoracostomy is extremely rare.

Presentation of case

We present a rare case of iatrogenic pneumopericardium in a 1 year and 7 months old female child for whom a left side tube thoracostomy was done using nasogastric tube for an indication of left empyema thoracis. Later, she developed progressively worsening shortness of breath and imaging revealed iatrogenic pneumopericardium. She was managed conservatively and discharged home in good condition.

Discussion

Iatrogenic pneumopericardium can have a range of presentations from being asymptomatic to features of cardiac tamponade. Patient management depends on the presence of tamponade effect and age of the patient. Infants tend to develop cardiac tamponade earlier urging surgical intervention but selected patients can be managed conservatively.

Conclusion

Iatrogenic pneumopericardium is a rare event but it might lead to death if not diagnosed and treated promptly. Although the tendency to develop tension pneumopericardium urging surgical intervention is high in pediatric patients, our patient has improved well with conservative management. While reporting of complications is not popular, this represents an opportunity to advance the safety during chest drain insertion.

Successful treatment with positive airway pressure ventilation for tension pneumopericardium after pericardiocentesis in a neonate: a case report

BACKGROUND

Pneumopericardium in neonates is often associated with respiratory diseases, of which positive pressure ventilation (PPV) is an exacerbating factor. Here, we present a neonate case of pneumopericardium after cardiac surgery which was resolved after applying PPV.

CASE PRESENTATION

A 28-day-old neonate with left recurrent nerve palsy after aortic reconstruction for interrupted aortic arch developed pericardial effusion. Pericardiocentesis was performed under general anesthesia, and a drainage tube was left in the pericardium. After extubation, stridor gradually exacerbated, following hemodynamic deterioration. A chest X-ray demonstrated pneumopericardium. Upper airway stenosis due to recurrent nerve palsy developed excessive negative pleural pressure, and air was drawn into pericardium via the insertion site of the drainage tube. After tracheal intubation and applying PPV, the pneumopericardium improved.

CONCLUSION

PPV does not always exacerbate pneumopericardium. In a patient with pericardial-atmosphere communication, increased inspiration effort can cause pneumopericardium, and PPV is a therapeutic option to alleviate the pneumopericardium.

Bilateral pneumothorax as possible atypical presentation of coronavirus disease 2019 (COVID-19). Respir Med Case Rep. 2020;31:101217. [PMID: 32934903 PMCID: PMC7483079 DOI: 10.1016/j.rmcr.2020.101217]

Coronavirus disease 2019 (COVID-19) is most frequently associated with a mild presentation of fever, cough, and shortness of breath. Typical radiographic findings of COVID-19 are bilateral ground-glass opacities on computed tomography (CT) scans. However, there have been instances of pneumothorax, giant bulla, and pneumomediastinum, mainly in elderly COVID-19 patients and predominately occurring at least one week after symptom onset. Here, we report a case where a healthy, young Hispanic man presented with three days of fever, cough, and dyspnea. On admission to the emergency department, he was found to have bilateral pneumothoraces, pneumomediastinum, and pneumopericardium requiring bilateral chest tubes. The patient had no predisposing risk factors for pneumothorax, such as a history of trauma, smoking, past intubations, asthma, high pressure oxygen delivery, or a history of prior pneumothorax. The only positive diagnostic test was a SARS-CoV-2 test by real-time reverse transcriptase-polymerase chain reaction assay. This case highlights the potential atypical presentation of a COVID-19 infection and is the first reported case, to our knowledge, that features bilateral spontaneous pneumothoraces, pneumomediastinum, and pneumopericardium as a probable rare presentation of COVID-19.

Colopericardial fistula presenting with massive rectal bleeding

Colopericardial fistulae constitute a condition with a very low prevalence and a high morbidity and mortality rate. In this case report, we discuss an 80-year-old male patient who presented to emergency services for massive rectal bleeding and signs of hypovolemic shock. Abdominal arteriography and upper gastrointestinal endoscopy were negative for bleeding. Findings indicative of fistula between the left ventricle and the transverse colon were described in computed tomography angiogram and the diagnosis was confirmed endoscopically. The patient was stabilized and the bleeding was self-limited. Direct communication between the gastrointestinal tract and the pericardium, or even with the heart itself, is a rare disease and constitutes a diagnostic challenge.

Pneumocystis jirovecii Pneumonia-Associated Acute Respiratory Distress Syndrome Complicated by Pneumomediastinum and Pneumopericardium in a Non-Human Immunodeficiency Virus-Infected Patient

Pneumocystis jirovecii pneumonia is widely known as a life-threatening opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). However, with the widespread use of highly active antiretroviral therapy (HAART) and effective anti-Pneumocystis antimicrobial prophylaxis, this entity has declined substantially in patients with human immunodeficiency virus (HIV) infection. Interestingly, the incidence of Pneumocystis jirovecii pneumonia has been increasing among patients without HIV infection, mainly as a consequence of the expanding use of chemotherapy and other immunosuppressive agents. Nevertheless, Pneumocystis jirovecii pneumonia remains an important cause of HIV- and non-HIV-related catastrophic complications. Pneumomediastinum and pneumopericardium are extremely uncommon events in patients with Pneumocystis jirovecii pneumonia. In this report, we described a unique case of Pneumocystis jirovecii pneumonia-associated acute respiratory distress syndrome (ARDS), complicated by pneumomediastinum and pneumopericardium in a non-HIV infected patient.

Cancer-Related Pneumopericardium: A Case Report and Literature Review

Pneumopericardium is a relatively rare entity mostly described in the literature as a result of causes such as penetrating/blunt trauma and iatrogenic causes during cardiothoracic procedures. We are presenting a case of pneumopericardium as a complication of progressed gastroesophageal junction tumor along with a literature review of all cancer-related pneumopericardium cases reported in the last decade. We present the case of a 65-year-old male with a past medical history significant for locally advanced gastroesophageal junction adenocarcinoma who presented to the hospital with complaints of shortness of breath and fever. A chest X-ray showed an intact esophageal stent along with radiolucency around the cardiac silhouette which suggested pneumopericardium. Computed tomography scan of the chest confirmed the presence of pneumopericardium in posterior pericardium with foci of gas above the esophageal stent likely to be communicating with the pericardium. An echocardiogram was obtained which showed no signs of tamponade. Given the advanced nature of the disease we applied a conservative management given that the pneumopericardium was deemed to be small with no tamponade. Goals of care were discussed with the patient and his family and the patient opted for comfort care measures. This case report prompted us to perform an extensive literature review of cancer-related pneumopericardium from 2008 to 2019. We found 11 cases where it was reported secondary to malignancies of different kinds. Our aim is to compile a review for clinicians to view varied presentations and better direct therapy dependent on the individual case and clinical presentation in patients with cancer-related pneumopericardium. Moreover, although pneumopericardium is rare, it should be considered in differential diagnosis in patients presenting with shortness of breath or chest pain especially with cancers involving the cardiothoracic region.

Post-surgical hydropneumopericardium: a case report of dramatic increase in the apparent size of pericardial effusion with positional changes

Background

Pneumopericardium is an uncommon clinical finding. It most commonly occurs after chest trauma but can also emerge as a complication following interventional or surgical procedures and can result in life-threatening complications. A high index of clinical suspicion should be present and once the condition is recognized, it should be managed promptly. Paucity of literature on pneumopericardium makes outlining any new case of paramount importance to emphasize the aspects of diagnosis and management of this rare condition.

Case summary

A 59-year-old woman with severe mitral valve and moderate tricuspid valve regurgitation underwent mitral and tricuspid valve repair with uneventful post-operative in-hospital stay. She presented 10 days after discharge with progressive shortness of breath. Chest X-ray revealed right hydropneumothorax. Transthoracic echocardiography (TTE) performed in the emergency department showed an apparently small pericardial effusion with patient in supine position; the effusion size increased substantially when imaging in left lateral decubitus, with presence of intrapericardial air bubbles. Computed tomography scan of the chest confirmed the presence of right hydropneumothorax and hydropneumopericardium, with a communicating pleuro-pericardial tract. The patient underwent chest tube placement which successfully decompressed both pleural and pericardial space.

Discussion

Hydropneumopericardium is a rare post-operative complication. Comprehensive TTE with imaging from multiple acoustic windows is mandatory when evaluating the extent of pericardial effusion. Presence of cardiac tamponade is crucial in determining the management plan.

[Colopericardial fistula after esophageal replacement surgery: case report and literature review]

INTRODUCTION

Colopericardial fistula is a rare complication of colonic replacement surgery whose incidence is unknown. Therefore, we present the following case and perform a literature review.

CLINICAL CASE

17-year-old female patient of age consults for respiratory distress and precordial pain of 5 days of evolution. Background: Long gap esophageal atresia (esophagostoma and feeding gastrostomy, subsequent colonic graft). Bilateral pneumonia is initially diagnosed. It rapidly evolves to a state of sepsis. On chest x-ray, pneumopericardium is observed. Water-soluble contrasted study confirms diagnosis of colopericardial fistula. Surgical treatment is established, despite this the patient dies due to respiratory distress.

COMMENT

Colopericardial fistula is a very serious entity with a high mortality rate. The clinical presentation and the complementary methods of diagnostic confirmation must be known in order to carry out the appropriate treatment.

Asymptomatic Pneumopericardium with Atrial Fibrillation after Pericardiocentesis: A Case Report

Air inside the pericardial cavity is called "pneumopericardium", which is a rare complication of pericardiocentesis. Pneumopericardium may resolve spontaneously or can complicate into tension pericardium, requiring urgent aspiration. We herein describe a 55-year-old man with pericardial effusion who underwent pericardiocentesis. The patient was completely asymptomatic after the procedure. Chest radiograph and computed tomography scan accidentally detected pneumopericardium, which was subsequently complicated by atrial fibrillation and necessitated pharmacological cardioversion. We found no case of asymptomatic pneumopericardium complicated by atrial fibrillation after pericardiocentesis in our literature review. Clinicians and cardiologists should do a post pericardiocentesis chest X-ray to diagnose pneumopericardium and prevent the catastrophic complications of tension pneumopericardium.

Pneumopericardium: a rare complication following pericardiocentesis

Pneumopericardium is the presence of air in the pericardial cavity. It is a rare case entity that has been reported most commonly after trauma, or spontaneously without any underlying cause in a healthy adult. Pneumopericardium following pericardiocentesis has been rarely reported in the literature. Pneumopericardium is often self-resolving and rarely requires a pericardial drain for treatment. We report a case of pneumopericardium presented with tamponade physiology following pericardiocentesis for tubercular pericardial effusion, requiring emergency pericardiectomy.

Cardiac A-lines in fast scan as a sign of pneumopericardium

Background

Traumatic pneumopericardium is rare and usually results from blunt injury. Diagnosis through clinical and chest X-ray is often difficult. Ultrasound findings of A-line artifacts in the cardiac window may suggest pneumopericardium.

Case presentation

A young man involved in a car accident and sustained blunt thoracic injuries, among others. As part of primary survey, FAST scan was performed. Subxiphoid view to look for evidence of pericardial effusion showed part of the cardiac image obscured by A-lines. Other cardiac windows showed only A-lines, as well. A suspicion of pneumopericardium was raised and CT scan confirmed the diagnosis.

Conclusions

Although FAST scan was originally used to look for presence of free fluid, with the knowledge of lung ultrasound for pneumothorax, our findings suggest that FAST scan can also be used to detect pneumopericardium.

A combination of rare complications 3 years after a dual-chamber pacemaker implantation

Late perforation of the atrial wall after pacemaker implantation frequently remains asymptomatic but may cause chest pain, dyspnea or syncope. Perforation can also lead to rarer complications such as hemoptysis and pneumopericardium. We present the case of a patient who developed progressive hemoptysis 3 years after a dual-chamber pacemaker implantation. Pacemaker interrogation showed stable impedance of the right atrial lead and stable pacing threshold values. CT revealed perforation of the right atrial wall by the RA-lead with consecutive pneumopericardium and diffuse lung bleeding of the right middle lobe. The patient was hemodynamically stable at all times. The right atrial lead was transvenously extracted and replaced without any further complications.

Gastropericardial fistula presenting with cardiac arrest: a case report

Introduction

Gastropericardial fistulas are rare conditions, with less than 100 reported cases. The diagnosis is associated with significant morbidity, prolonged hospitalization and often has a fatal outcome.

Case presentation

We describe a unique case of cardiac arrest caused by pneumopericardium and cardiac tamponade as the acute presentation of a gastropericardial fistula, in a patient admitted with an infection of unknown origin. Rapid return of spontaneous circulation occurred, and a computed tomography scan revealed the diagnosis. A benign penetrating ulcer was found on gastroscopy, and surgical management with laparotomy and gastrorrhaphy was performed. The patient had no risk factors for gastric ulceration. However, he had significant comorbidity, which makes survival through a complicated postoperative course to full recovery remarkable.

Discussion

This case shows that pneumopericardium due to a penetrating benign gastric ulcer can cause cardiac tamponade, and illustrates the value of a multidisciplinary approach to management.

Thoracic trauma in fatal falls from height - Traumatic pneumopericardium correlates with height of fall and severe injury

Pneumopericardium (PPC) describes the collection of gas in the pericardial sac. In tension Pneumopericardium (tPPC), this collection of gas may lead to cardiac tamponade. PPC following blunt trauma is considered a rare finding, as reflected by the low number of case reports on the topic. We analyzed the prevalence and pathophysiology of PPC and the associated trauma in 44 cases of falls from height. We retrospectively analyzed postmortem CT data and autopsy reports of fatal falls in the period March 2014-2017. A valid estimation of the height of the fall and a documented impact on an even and hard surface were inclusion criteria. A total of 44 cases were included in the study. We identified PPC in 18 of the 44 cases, and it was associated with an increased height of the fall, alongside aortic, pericardial, and myocardial ruptures. All cases with PPC also presented with bilateral pneumothorax. Five cases presented with a "ballooning" pericardium, indicating tPPC. PPC is a common finding in cases of falls from great heights. Due to a significant correlation with height and thus impact severity, PPC may be used as a reconstructive element in medico-legal investigations. Association with trauma makes PPC a sign of severe thoracic injury in postmortem and clinical radiology.

Pneumomediastinum and pneumopericardium following blunt thoracic trauma: much ado about nothing?

PURPOSE

Pneumomediastinum is the hallmark of intrathoracic aerodigestive trauma, but rare following blunt injury.

AIM

review of blunt thoracic trauma (BTC) for the incidence and outcome of patients with pneumomediastinum or pneumopericardium (PM/PC) on Computerised Tomographic scanning.

METHODS

Admissions to the level I trauma ICU at IALCH, Durban, ZA following BTC from April 2007 to March 2014. Patients with Chest-CT-scan were analysed. Variables included age, sex, mechanism of injury, and Injury Severity Score (ISS). Specific injury patterns: isolated thoracic trauma, flail chest, bilateral injury and presence of haemothorax or pneumothorax were analysed.

RESULTS

Three hundred and eighty-nine patients were included. Males (70.9%) accounted for the majority of patients. The median Injury Severity Score was 32 (IQR 24-41). Motor vehicle collisions accounted for 94% of injury mechanisms. Twenty-three (5.9%) were identified with pneumomediastinum, 6 (1.5%) with both pneumomediastinum and pneumopericardium, and 1 (0.2%) with isolated pneumopericardium. No patient required surgery for thoracic trauma. Increasing age (p < 0.001) and a flail chest (p = 0.005) were significant associations. The mortality rate was almost identical in those with or without air within the mediastinum. No patient died from a missed mediastinal aero-digestive injury.

CONCLUSION

The presence of PM/PC following BTC is incidental and benign. Increased injury severity with a flail chest is associated with a significant increase in the presence of free gas within the mediastinum. In the absence of complications, no obvious injury to the intrathoracic aero-digestive tract on CT scanning, and no difference in mortality, a conservative management policy is warranted.

[Thoracic endometriosis complicated with pneumopericard and iterative pneumothorax due to bullous dystrophy]

Thoracic endometriosis is a rare entity characterized by presence of endometrial tissue in pleura, lung parenchyma or airways. Most frequent manifestations are catamenial pneumothorax, hemothorax, hemoptysis and pulmonary nodules. We report here a rare case of a woman with thoracic endometriosis who developed iterative pneumothorax and pneumopericardium on bilateral bullous pulmonary dystrophy. She was a 37-year-old woman without any tobacco exposure and with previous history of pleural tuberculosis treated 5 years earlier. She was first referred to our centre for right pleuro-pneumothorax and hemorrhagic ascites. Pleural fluid examinations did not show any tuberculosis relapse, the evolution was favorable after thoracic drainage and there was no parenchymal lung abnormality on CT scan after surgery. Celioscopic peritoneal examination revealed stage IV peritoneal endometriosis. One year later, she was admitted for left catamenial pneumothorax. Thoracic CT scan showed apparition of large subpleural bulla. She underwent thoracotomy for bulla resection and left partial pleurectomy. Two years later, she was hospitalized for right pneumothorax and compressive pneumopericardium. Surgical lung biopsies confirmed pleuropulmonary endometriosis. Thoracotomy was performed for talcage pleurodesis and diaphragmatic leakages sutures. Lung bulla are rare in thoracic endometriosis, mechanism of their formation remains unknown. Pericardial involvement is rare in endometriosis; we report here a unique case of pneumopericardium.

Gastric perforation into the pericardium

Gastric perforation into the pericardium is an extremely rare but lethal condition. Only a few case reports have been described in the literature. It is difficult to diagnose these patients with clinical evaluation. Accurate and immediate diagnosis of the intestinal perforation is vital. Herein, we present a 56-year old female patient with gastric perforation into the pericardium due to benign gastric ulcer diagnosed with computed tomography (CT). We also emphasized the imaging findings in the diagnosis of intestinal perforation into the pericardium.

Tension pneumopericardium in a multiply injured child

Tension pneumopericardium is a rare disease that is very difficult to diagnose. A 3-year old child was run over by a minibus. Computed tomography showed bilateral pneumothorax, multiple rib fractures on both sides, and a hepatic laceration. The massive blunt thoracic trauma caused entrapped air in the pericardium, and a tension pneumoprecordium developed abruptly. We report this unique case of tension pneumopericardium in a child, and the subsequent emergency surgery and damage control measures.

Pneumopericardium as a non-small-cell lung carcinoma complication

Below we present a case of a young man with symptoms of progressive weakness, fever, cough, rapid decrease in body weight and the presence of a tumor in the left axillary region. The chest radiography and echocardiography revealed gas bubbles in the pericardium. The more detailed diagnostics and computed tomography of the chest showed an infiltration of the left lung cavity and a fistula among the bronchus, pleural and pericardial cavities. Further diagnostics demonstrated that the pneumopericardium (diagnosed by means of chest radiograph and echocardiography) was a complication of a primary non-small-cell lung carcinoma.

Gastropericardial fistula: getting to the heart of the matter

Background

Gastropericardial fistula is a rare life-threatening condition, being reported only 65 times in modern literature.

Case presentation

A 67 year-old man who presented with weight loss, chest pain and epigastric pain was found to have pericardial effusion and pneumopericardium on computed imaging. Endoscopy and histology confirmed a gastric adenocarcinoma within a hiatus hernia, which had fistulated to the pericardium. His condition was complicated by pulmonary emboli and lobar infarction, all contributing to rapid deterioration and death.

Conclusion

Review of all previously published cases reveals that factors which predict poorer prognosis are older age, cancer etiology and conservative management. Conversely, protective factors include younger age at presentation, previous gastroesophageal surgery or ulcers as an etiology, and aggressive procedural and surgical management. Although the diagnosis is viewed as largely fatal by many clinicians, operative management has contributed to a statistically significant reduction in mortality from 69 % in the pre-2000 era to 11 % in the post-2000 era. This study summarizes diagnostic methods and treatment interventions and prognostication in this rare condition.

Tension pneumopericardium in blunt thoracic trauma

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Tension pneumopericardium is a cause of shock in thoracic trauma.

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It should be regarded in hemodynamically unstable patients with blunt chest trauma.

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Immediate pericardium decompression may save the patient’s life.

Introduction

Pneumopericardium, defined as the presence of gas in the pericardial sac, is a rare condition caused mostly by trauma. Tension pneumopericardium is a cause of hemodynamic instability; hence, it consists in a life-threatening situation and should be regarded in blunt chest trauma.

Case report

A 51-year-old male was victim of a 4 m fall and burial. He was stable upon admission and presented a simple pneumopericardium and pneumomediastinum on CT. While being submitted to an upper digestive endoscopy he presented respiratory failure and had to be intubated, suddenly evolving to shock. He was promptly referred to the operating room; a pericardial window confirmed tension pneumopericardium and immediately hemodynamic stability was restored. A pericardial drain was placed and kept for 15 days. He was discharged at the 18th day post-trauma after a satisfactory recovery at the trauma ICU.

Discussion

Blunt thoracic trauma causes pneumopericardium by various mechanisms. Tension pneumopericardium is a possible outcome, probably related to positive-pressure ventilation. It leads to hemodynamic instability and requires immediate decompression and placement of a pericardial drain.

Pneumopericardium: A Rare Complication of Pericardiocentesis

Pneumopericardium is defined by the presence of air in the pericardial cavity. It is a rare entity occurring most commonly after trauma. Pneumopericardium resulting after pericardiocentesis is even rarer. We report a case of 46-year-old man, with end-stage renal disease on chronic hemodialysis and who developed a large circumferential pericardial effusion of 40 mm in diastole with swinging heart and diastolic right atrium collapse requiring pericardiocentesis. Few days after, the patient complained of pleuritic chest pain and echocardiogram revealed several tiny sparkling echogenic spots swirling in the pericardial sac. Computed tomography scans revealed a marked anterior pneumopericardium that was conservatively managed.

Gastropericardial fistula: radiologic findings and literature review

BACKGROUND

Gastropericardial fistula, a rare condition characterized by an abnormal communication between the stomach and the pericardium, is an emergency as sequelae such as cardiac tamponade and sepsis may lead to hemodynamic instability and death. We aimed to summarize the surgical and radiologic findings of the reported cases published to date, describe their pertinent surgical history, and present an algorithm for diagnosis.

METHODS

The Pubmed database was searched using the terms: gastropericardial, pericardiogastric, pneumopericardium, pericardial, and pneumopericardium with the term "fistula" added to each term. The search was limited to January 2000-October 2015 and English language publications.

RESULTS

Thirty five cases were identified. The most common etiology was prior esophageal and/or gastric surgery (80% of cases; esophagectomy = 26%/gastrointestinal reflux disease associated surgery = 23%/bariatric surgery = 11%/partial gastrectomy = 6%/other = 20%). The average duration between presentation and surgery was 7.3 ± 6.2 years (SD). Radiology typically played a crucial role in diagnosis with computed tomography most commonly demonstrated to be the most appropriate modality to demonstrate the fistula and assist in surgical planning. Contrast studies were frequently helpful to confirm the diagnosis. Chest x-ray findings including pneumopericardium and pericardial thickening were contributory but nonspecific. Esophagoduodenoscopy characterized the fistula in cases where imaging was equivocal and may provide therapeutic options.

CONCLUSIONS

We present the clinical radiologic findings of the 35 cases of gastropericardial fistula reported. This is the first literature review of gastropericardial fistula to focus on the effectiveness of these various diagnostic modalities and to present an algorithm for diagnosis.

Tension Pneumopericardium after Pericardiocentesis

Pneumopericardium is defined as the presence of air inside the pericardial space. Usually, it is reported as a complication of blunt or penetrating chest trauma, but rare iatrogenic and spontaneous cases have been reported. Pneumopericardium is relatively stable if it does not generate a tension effect on the heart. However, it may progress to tension pneumopericardium, which requires immediate pericardial aspiration. We report a case of iatrogenic pneumopericardium occurred in a 70-year-old man who presented dyspnea at emergency department. The patient underwent pericardiocentesis for cardiac tamponade due to large pericardial effusion, and iatrogenic tension pneumopericardium occurred due to misuse of the drainage device. After evacuating the pericardial air through the previously implanted catheter, the patient became stable. We report this case to increase the awareness of this fatal condition and to help increase the use of precautions against the development of this condition during emergency procedures.

[Pneumopericardium due to thorax compression : Overlooked resuscitation injury]

On postoperative day 15 after right upper lobectomy of a non-small cell lung cancer a 75-year-old patient developed bradycardia followed by asystole during hospitalization on the intensive care unit. After approximately 4 min of chest compressions, circulatory function was re-established but the patient suffered from tachycardia and required continuous vasopressor support. To exclude hypovolemia and assess contractility, transthoracic echocardiography (TTE) was conducted. During the TTE examination neither the intensive care physician nor the cardiologist on call could obtain usable images, which was explained by the lack of experience of both physicians with TTE. Both chest ultrasound and chest x-ray imaging did not reveal any signs of a pneumothorax. A small zone of increased transparency in the cardiac silhouette was not considered to be of pathological relevance. Slowly, the patient recovered. On the following day, a thoracic computed tomography (CT) scan showed an extensive pneumopericardium of the entire pericardium with a seam width of 3 cm. Because of the patient's clinical improvement, a decision for a conservative therapeutic approach was made and 24 h later the seam width was reduced to 2 cm and 9 days later it was no longer detectable. After a total stay of 24 days in the intensive care unit the patient was transferred to a long-term pulmonary care weaning facility. In retrospect, the pneumopericardium as a rare resuscitation injury was the cause for the poor TTE conditions and was overlooked due to a fixation error, because too much attention had been focused only on the detection of a pneumothorax.

Management of a pneumopericardium due to penetrating trauma

INTRODUCTION

A pneumopericardium presenting after penetrating chest trauma is a rare event. The surgical management of this clinical problem has not been clearly defined. The aim of this study was to document the mode of presentation and to suggest a protocol for management.

PATIENT AND METHODS

A review of a prospectively collected cardiac database of patients presenting to Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 with a pneumopericardium on chest X-ray after penetrating trauma.

RESULTS

There were 27 patients with a pneumopericardium (mean age 25 years, range 17-36). The mechanism of injury was a stab wound to the chest in 26 patients and a single patient with multiple low velocity gunshot wounds. Six patients (22%) were unstable and required emergency surgery. One of these patients presented with a tension pneumopericardium. Twenty-one patients were initially stable. Two of these (10%) patients later developed a tension pneumopericardium within 24-h and were taken to theatre. The remaining 19 patients were managed with a subxiphoid pericardial window (SPW) at between 24 and 48h post admission. Ten of these 19 patients (52%) were positive for a haemopericardium. Only 4 of the 19 underwent a sternotomy and only two of these had cardiac injuries that had sealed. There were no deaths in this series.

CONCLUSION

Patients with a penetrating chest injury with a pneumopericardium who are unstable require emergency surgery. A delayed tension pneumopericardium developed in 10% of patients who were initially stable. It is our recommendation that all stable patients with a pneumopericardium after penetrating chest trauma should undergo a SPW. A sternotomy is not required in stable patients.

Spontaneous Pneumomediastinum, Pneumopericardium, and Pneumothorax with Respiratory Failure in a Patient with AIDS and Pneumocystis jirovecii Pneumonia

Spontaneous pneumothorax occurs in up to 35% of patients with Pneumocystis jirovecii pneumonia. However, spontaneous pneumomediastinum and pneumopericardium are uncommon complications in patients infected with human immunodeficiency virus, with no reported incidence rates, even among patients with acquired immunodeficiency syndrome (AIDS) and P. jirovecii pneumonia. We report a case of spontaneous pneumomediastinum, pneumopericardium, and pneumothorax with respiratory failure during treatment of P. jirovecii pneumonia in a patient with AIDS; the P. jirovecii infection was confirmed by performing methenamine silver staining of bronchoalveolar lavage specimens. This case suggests that spontaneous pneumomediastinum and pneumopericardium should be considered in patients with AIDS and P. jirovecii pneumonia.

Long and wrong way: Unintended pericardial catheter insertion through stomach

Complications of percutaneous pericardial catheter insertion for pericardial effusion are rare. We describe a rare complication of percutaneous pericardial catheter insertion that penetrated the stomach and diaphragm before getting into the pericardial sac in a patient with lymphoma. The misplaced catheter was extracted surgically and subxiphoid pericardial tube insertion with pleural pericardial window was performed. <Learning objective: Although similar outcomes have been reported with both percutaneous and subxiphoid techniques, major complications may arise with the percutaneous technique. This case emphasizes that percutaneous pericardial catheter insertion may have serious complications and these procedures should be performed by experienced clinicians with the standby of a cardiac team.>.