Epipericardial fat necrosis: an underdiagnosed condition

Epipericardial fat necrosis: A case report

Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain and is a benign and self-limiting condition. It is important to distinguish epipericardial fat necrosis from other diseases that cause acute chest pain, such as acute myocardial infarction, pulmonary embolism, and acute pericarditis, because conservative treatment is recommended for epipericardial fat necrosis. This report presents the case of a 25-year-old man with severe pleuritic chest pain located on the left anterior side that was associated with dyspnea. Electrocardiogram and laboratory data were normal, except for a slight elevation of C-reactive protein level. Contrast-enhanced chest computed tomography revealed a fatty ovoid lesion surrounded by a thick rim on the left side of the pericardial fat. Fat stranding was observed both inside and adjacent to the fatty ovoid lesion. A slight contrast enhancement of the thick rim and a slight linear enhancement inside the lesion were observed. Furthermore, a small amount of left pleural effusion was observed. The patient was diagnosed with epipericardial fat necrosis and treated with analgesics, and the symptoms improved 1 week after the emergency department visit. Radiologists should be familiar with epipericardial fat necrosis to prevent overlooking and misdiagnosing the condition.

Epipericardial fat necrosis diagnosed by cardiac CT in a patient with apical hypertrophic cardiomyopathy

Epipericardial fat necrosis (EFN) is a rare benign cause of chest pain, that is frequently overlooked. EFN involves the necrosis of fat tissue in the mediastinum, and presents on computed tomography (CT) as an ovoid lesion of fat attenuation surrounded by a rim of soft tissue attenuation. This case report describes a case of a 50-year-old man diagnosed with EFN on cardiac CT, which was incidentally associated with apical hypertrophic myocardiopathy. Notably, the detection of EFN proved difficult on arterial phase images during coronary CT angiography, whereas it was much easier to detect on delayed phase images. EFN should be considered in the differential diagnosis of chest pain, and careful examination of mediastinal fat is crucial for accurate diagnosis.

Case report on the radiographic features of epipericardial fat necrosis in a patient presenting with acute chest pain

Epipericardial fat necrosis (EFN) is a rare and benign condition. The three cardinal features of EFN are acute pleuritic chest pain, radiological features of an encapsulated fatty lesion within the epipericardial fat and the presence of inflammation within the surrounding pericardium. The exact aetiology is still unknown, and there are no known risk factors. The condition appears to be a transient process with no associated long-term complications. In this case study, we demonstrate the multitude of radiological features associated with this condition. A 29-year-old Caucasian female presented with acute pleuritic chest pain. There were no acute changes on her blood work, electrocardiogram (ECG) or echocardiogram. The chest radiograph showed an opacity projected within the anterior mediastinum. Further imaging, with computed tomography (CT) chest with contrast, was performed to define the characteristics of the opacity. This confirmed an encapsulated, mixed fat, soft tissue density in the left pericardiac region deemed to represent EFN. Follow-up magnetic resonance (MR) cardiac imaging at 1, 4 and 12 months demonstrated the self-resolving characteristics of this condition. EFN is a rare differential diagnosis to consider in patients presenting with acute pleuritic chest pain when laboratory tests are normal and there are no acute ECG findings. EFN should be excluded by imaging with CT or MRI of the heart. We have demonstrated through follow-up MR imaging the progression and resolution of EFN over 12 months.

Epipericardial fat necrosis in chest CT and MRI: a case report of an unusual cause of chest pain associated with the initial diagnosis of undifferentiated connective tissue disease

BACKGROUND

Epipericardial fat necrosis (EFN) is a benign and self-limited condition of unknown cause with a good prognosis, usually affecting otherwise healthy patients. Clinically, it presents with severe acute left pleuritic chest pain, often leading the patient to the Emergency Room (ER).

CASE PRESENTATION

A 23-year-old male, smoker (5 pack-years), was evaluated in the ER due to left pleuritic chest pain, worsening with deep breathing and Valsalva maneuver. It was not associated with trauma and did not present other symptoms. The physical examination was unremarkable. The arterial blood gases while breathing room air and the laboratory tests, including D-dimers and high-sensitivity cardiac Troponin T, were normal. The chest radiograph, electrocardiogram, and transthoracic echocardiogram showed no abnormalities. A computed tomography (CT) pulmonary angiogram showed no signs of pulmonary embolism but depicted at the left cardiophrenic angle a focal 3 cm ovoid-shaped fat lesion with stranding and thin soft tissue margins, consistent with necrosis of the epicardial fat, which was confirmed by magnetic resonance (MRI) of the chest. The patient was medicated with ibuprofen and pantoprazole, with clinical improvement in four weeks. At a two-month follow-up, he was asymptomatic and presented radiologic resolution of the inflammatory changes of the epicardial fat of the left cardiophrenic angle on chest CT. Laboratory tests revealed positive antinuclear antibodies, positive anti-RNP antibody, and positive lupus anticoagulant. The patient complained of biphasic Raynaud's phenomenon initiated five years ago, and a diagnosis of undifferentiated connective tissue disease (UCTD) was made.

CONCLUSIONS

This case report highlights the diagnosis of EFN as a rare and frequently unknown clinical condition, which should be considered in the differential diagnosis of acute chest pain. It can mimic emergent conditions such as pulmonary embolism, acute coronary syndrome, or acute pericarditis. The diagnosis is confirmed by CT of the thorax or MRI. The treatment is supportive and usually includes non-steroidal anti-inflammatory drugs. The association of EFN with UCTD has not been previously described in the medical literature.

Epipericardial fat necrosis as a differential diagnosis of acute chest pain: a case report and algorithm proposal for diagnostic approach

Chest pain is a frequent, potentially life-threatening condition in the emergency department and requires immediate investigation and treatment. This case report highlights a rare differential diagnosis of pleuritic chest pain: epipericardial fat necrosis. A 29-year-old man presented with normal clinical evaluation, electrocardiography, point-of-care ultrasound, and unremarkable laboratory tests. The initial hypothesis was acute pleuritis. Chest radiography revealed peri-cardiac nonspecific findings, and computed tomography revealed epicardial fat necrosis. Despite the rarity of this condition, accurate diagnosis allows for better practices. An algorithm for a diagnostic approach is proposed.

Man with Pleuritic Chest Pain

CASE PRESENTATION

We describe a case of epipericardial fat necrosis.

DISCUSSION

Epipericardial fat necrosis is an inflammatory condition in which the pericardial fat pad necrotizes resulting in surrounding inflammation. This condition mimics more ominous pathology in clinical presentation and radiographic findings. Management is supportive with oral analgesics.

Epicardial Fat Necrosis After COVID-19 Infection: A Case Report

Epipericardial or epicardial fat necrosis (EFN) is a self-limited inflammatory process occurring in the mediastinal fat surrounding the heart. It is an uncommon cause of acute chest pain and mimics more critical clinical disorders such as acute coronary syndrome, aortic dissection, and pulmonary embolism. However, EFN is frequently overlooked and under-recognized in emergency departments (EDs) owing to the unfamiliarity of this condition among physicians and radiologists. Herein, we present the case of a previously healthy young male patient, with a recent history of mild COVID-19 infection (two weeks before presentation), who presented to the ED for acute chest pain. Paraclinical evaluation including computed tomography (CT) of the chest revealed fat stranding along with the left epicardial fat pad in favor of EFN.

Case report: epipericardial fat necrosis—a rare cause of chest pain

Background

Epipericardial fat necrosis (EFN) is a rare cause of chest pain, which is often unrecognized.

Case summary

A 58-year-old man previously known with a transient ischaemic attack presented with a sharp, substernal chest pain. Pulmonary embolism was ruled out by computed tomography (CT) angiography. However, CT angiography revealed an inhomogeneous epipericardial mass. On cardiovascular magnetic resonance imaging, the mass had an inhomogeneous signal intensity without infiltration of surrounding tissue. Late gadolinium enhancement imaging showed subtle hyperenhancement. Tissue characterization by means of parametric mapping revealed very low native T1 relaxation times and increased T2 relaxation times. In conclusion, the epipericardial mass showed fibrofatty inflammatory markers, suggestive of EFN. The chest pain resolved spontaneously. Follow-up CT 3 months later showed a marked regression of the mass which confirmed the diagnosis EFN.

Discussion

Epipericardial fat necrosis is a benign and self-limiting inflammatory cause of chest pain, which can be diagnosed with multi-modality imaging and must not be overlooked in the differential diagnosis of patients with acute pleuritic chest pain.

Epipericardial Fat Necrosis: A Retrospective Analysis in Japan

Objective Epipericardial fat necrosis (EFN) has been considered to be a rare cause of acute chest pain, and especially important for emergency physicians. Chest computed tomography (CT) is often used for the diagnosis of EFN after excluding life-threatening states, such as acute coronary syndrome and pulmonary embolism. While the proportion of EFN patients who underwent chest CT in emergency departments is being clarified, little is still known about other departments in Japan. To investigate the proportion of EFN patients who underwent chest CT for acute chest pain in various departments. Methods Chest CT performed from January 2015 to July 2020 in Asahikawa Medical University Hospital in Japan was retrospectively analyzed in this study. All images were reviewed by two radiologists. Results There were 373 outpatients identified by a search using the word 'chest pain' who underwent chest CT. Eight patients satisfying the imaging criteria were diagnosed with EFN. The proportions of patients diagnosed with EFN were 10.7%, 4.8%, 2.8%, 0.9% and 0% in the departments of general medicine, cardiovascular surgery, emergency medicine, cardiovascular internal medicine and respiratory medicine, respectively. Only 12.5% of the patients were correctly diagnosed with EFN, and the other patients were treated for musculoskeletal symptoms, acute pericarditis or hypochondriasis. Conclusion EFN is not rare and is often overlooked in various departments. All physicians as well as emergency physicians should consider the possibility of EFN as the cause of pleuritic chest pain.

Epipericardial Fat Necrosis: A Concise Review of Literature

Epipericardial fat necrosis (EFN) is an inflammatory process that occurs in the mediastinal fat surrounding the heart. It is a rare cause of acute chest pain and mimics more ominous clinical conditions such as acute coronary syndrome, aortic dissection, and pulmonary embolism. Clinicians are often not familiar with this condition due to its infrequent occurrence, and traditional textbooks of medicine and cardiology have not covered this topic adequately. In the past, EFN had been managed primarily with thoracotomy and surgical excision. This has changed with advances in imaging techniques and their more frequent utilization. Computed tomography (CT) of the chest is essential for the diagnosis of EFN as it allows for the evaluation of the nature and precise location of the lesion. Magnetic resonance imaging helps to differentiate EFN from other mediastinal fatty lesions such as lipomas or liposarcomas. The clinical presentation of acute chest pain along with CT findings of the encapsulated fatty pericardial lesion is adequate for diagnosis. Our review describes the emerging role of imaging in diagnosis and change in management over the last few years.

Epipericardial Fat Necrosis: A Case Report and a Review of the Literature

Epipericardial fat necrosis (EFN), also known as pericardial or mediastinal fat necrosis, has until lately been considered an unusual cause of acute chest pain. Due to increased use of computed tomography (CT) and other imaging techniques, EFN is now believed to be an under-diagnosed cause of acute chest pain. We here present a patient with a short history of acute, left-sided pleuritic chest pain and dyspnoea, with total resolution of symptoms upon few days with nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. Chest X-ray showed a paracardial opacity with ipsilateral pleural effusion, echocardiography revealed features of EFN, and CT scan demonstrated the cardinal lesion of EFN—an ovoid, fat-containing paracardial mass with surrounding inflammatory stranding. There was a near to full radiological resolution in 3 weeks.

Diagnosis of Epipericardial Fat Necrosis on multimodality imaging in a pediatric patient: a case report and review of the literature

This is a case report of a 13-year-old male, presented to the Emergency Department complaining of a sudden onset left-sided pleuritic chest pain for 1 day. He was found to have a mass in the left Epipericardial fat with fat stranding and pleural effusion supporting the diagnosis of Epipericardial Fat Necrosis. The findings were established by Computed tomography and Ultrasound, and the final diagnosis was confirmed by Magnetic resonance imaging. Subsequently, the patient was discharged on analgesia; reassessment one-month later showed clinical improvement with no symptom recurrence. Repeated Ultrasound demonstrated a marked decrease in size and echogenicity of the mass. In this paper we review the clinical and radiological manifestations of Epipericardial fat necrosis and the different management approaches taken over the years.

Epipericardial fat necrosis as cause of chest pain in patient after heart transplantation

Epipericardial fat necrosis is an uncommon clinical condition of unknown etiology. It typically presents as acute pleuritic chest pain and should be differentiated from acute pulmonary embolism and acute coronary syndrome. This condition is diagnosed by characteristic chest computed tomography findings of an ovoid mediastinal fatty lesion with intrinsic and surrounding soft-tissue stranding. Treatment of epipericardial fat necrosis includes the administration of anti-inflammatory agents, and symptoms usually resolve within a few days after treatment initiation. This disease entity has rarely been reported since it was first described in 1957. Most current knowledge of epipericardial fat necrosis is based on case reports that describe this condition in previously healthy individuals. We present the case of a 39-year-old woman with a history of heart transplant, who presented with chest pain secondary to epipericardial fat necrosis. Serial computed tomography revealed lesion resolution after appropriate treatment.

Imaging diagnosis of epipericardial fat necrosis in children

Epipericardial fat necrosis is a benign, self-limited entity increasingly recognized as a cause of chest pain in adults. Epipericardial fat necrosis typically presents with acute pleuritic chest pain or abdominal pain and affects otherwise healthy individuals who characteristically have negative physical exams, laboratory tests and other ancillary tests such as electrocardiograms. We report the imaging findings of epipericardial fat necrosis in a 15-year-old boy and additional images of a case in an 8-year-old boy. Pediatric radiologists should be cognizant of this condition to ensure appropriate diagnosis and avoid unnecessary invasive procedures.

Epipericardial fat necrosis as a differential diagnosis of chest pain-A case report

Epipericardial fat necrosis (EFN) is an uncommon self-limiting benign condition that can present with substantial chest pain. We present a case of an otherwise healthy 42-year-old man who presented with severe chest pain in the emergency department. Initial cardiopulmonary workup was unrevealing. Contrast-enhanced thorax CT demonstrated an increased radiolucency and nodularity of anterior pericardial fat consistent with epipericardial fat necrosis. The transthoracic echocardiogram was normal, and cardiac magnetic resonance imaging confirmed the lesion. Combined anti-inflammatory therapy was started with favorable evolution.

The imaging appearances of various pericardial disorders

The pericardium could be involved in a variety of clinical disorders. The imaging findings are not specific for an individual pathology in most of the cases; however, patient’s clinical history may guide radiologist to a definitive diagnosis. Congenital absence of the pericardium could be recognized with the imaging appearance of interposed lung tissue between the main pulmonary artery and aorta. Pericardial effusion is a non-specific condition that may occur due to inflammatory, infectious, and neoplastic disorders. Cardiac tamponade may occur in case of massive or rapid accumulation of fluid in the pericardial sac. Pericardial calcification is a common and easily identified entity on a computed tomography (CT) scan. Presence of calcification and/or fibrosis may result in pericardial constriction. Nevertheless, the pulsation of an adjacent coronary artery may prevent calcification formation in a focal area and consequently may result in pericardial diverticulum containing epicardial fat and coronary artery. The imaging findings encountered in patients with pericardial hydatid disease and Erdheim-Chester disease may mimic those of pericardial neoplasia. Pericardial adhesions and pedicled fat flaps may cause confusion on a CT scan in the post-surgical period following cardiac surgery. Pericardial fat necrosis can be diagnosed by CT in patients with chest pain. The radiologists should be familiar with the medical devices placed in pericardial space for certain individual indications. A pericardial patch and temporary epicardial pacemaker wires could be identified on a CT scan.

A 35-Year-Old Woman With Acute Pleuritic Chest Pain and an Unusual Mediastinal Opacity

CASE PRESENTATION

A 35-year-old woman came to the ED following 2 days of chest pain. She was a nonsmoker, taking no medications, and not using a contraceptive pill. The patient had no history of recent travel but had given birth (full-term pregnancy) 4 months earlier. She described nonradiating, left-sided pleuritic chest pain with no associated dyspnea, cough, sputum, or sweating.

Thin-section CT findings of thoracolithiasis

PURPOSE

To review thin-section CT findings of thoracolithiasis.

MATERIALS AND METHODS

Thirty-three thin-section CT scans of 9 patients with thoracolithiasis diagnosed between 2008 and 2016 were reviewed for the location, shape, longest diameter, and calcification of each freely mobile nodule (thoracolith) and for the presence of coexisting abnormalities.

RESULTS

The mean age of 9 patients (5 women) was 65.8 years (SD 14.9; range 37-83 years). Eight were > 50 years of age. Three patients had two thoracoliths, and the remaining 6 patients had one. Thoracoliths were in the left (n = 9) or right (n = 3) pleural cavity, with most in the lower pleural cavity. Nine thoracoliths were found to be larger at follow-up. The median diameters of the 12 thoracoliths were 4.9 mm (range 2.1-10.6 mm) and 6.2 mm (range 3.6-11.0 mm) on the initial and latest follow-up CT scans, respectively. Concomitant old granulomatous disease (n = 6) and diffuse systemic sclerosis-related interstitial lung disease (n = 2) were noted.

CONCLUSION

Thoracolithiasis can manifest as one or two small calcified nodules. It tends to occur in the left lower pleural cavity, occur in a patient aged > 50 years, be larger on follow-up, and coincide with other diseases.

Epipericardial fat necrosis as a cause of acute chest pain

Acute chest pain is one of the most common reasons for presentation to the emergency department. Although most etiologies of chest pain are easy to clinically ascertain with routine history, physical, and laboratory examinations, we present an important benign cause of acute chest pain that may mimic acute coronary syndrome.