Pneumopericardium in a child - "halo sign" on chest x-ray: A Case Report

A 5 year old boy with acute ly mphoblastic leukaemia on chemotherapy presented with chest pain and vomiting for two days after an elective procedure under general anaesthesia. H is ches t x-ray was remarkabl e for a promin ent halo sign, an air gap surrounding the he art indicat ing a large pneumope ricardium. Alth ough the pneu mo pericardium could not be appre ciated on an echocardiogram, the child developed clinical sig ns of cardiac t amponade. Attem pts to evacu ate the pneumopericardium were unsuccessful leading to death.

Spontaneous pneumomediastinum associated with subcutaneous emphysema, pneumopericardium and pneumothorax: a rare association complicating measles

A unique case of severe measles complicated by multiple features of gas accumulation is described, on the ground of the available literature evidences. Complications from measles have been reported in every organ system and they may vary by age and underlying conditions. Pneumomediastinum is usually associated with subcutaneous emphysema and pneumopericardium, but rarely associated with pneumothorax. We report extremely rare simultaneous occurrence of self-limiting pneumomediastinum, pneumopericardium, subcutaneous neck and chest region emphysema, and pneumothorax, in a 19-year-old girl with measles. A review of the literature has documented only one previous report of spontaneous pneumomediastinum, subcutaneous emphysema and pneumothorax in the course of measles, and no previous cases reported the association of pneumomediastinum, subcutaneous emphysema, pneumopericardium and pneumothorax complicating measles.

Tension Pneumopericardium Causing Cardiogenic Shock due to Blunt Injury to the Chest

Pneumopericardium is an exceptionally uncommon phenomenon in the setting of blunt polytrauma. It is imperative for trauma providers to identify tension pneumopericardium despite its rarity. A 22-year-old male motorcyclist presented to the hospital after colliding with a car going approximately 50 mph. The patient was hemodynamically unstable and had diminished breath sounds bilaterally. Bilateral chest tubes were placed, yielding little improvement in condition. While obtaining CT imaging, pneumopericardium was promptly identified. Pulses were lost immediately before pericardiocentesis, and resuscitative thoracotomy was performed. The pericardial sac was tense and an immediate gush of air released upon incising the sac. The patient was taken immediately to the Operating Room for further exploration and repair.

Conservative management of pneumopericardium: A case of unexpected success

A 79-year-old male with severe aortic stenosis was admitted with syncope and cranioencephalic traumatism with major nasal hemorrhage. While being prepared for surgical aortic valve replacement, a high-degree atrioventricular block was detected and a definite pacemaker was implanted.

Very late-onset atrial lead perforation leading to pneumopericardium

BACKGROUND

Atrial lead perforation may lead to pneumopericardium or pneumothorax within a few days of device implantation.

METHODS AND RESULTS

We report a case of atrial lead perforation 6 years after cardiac resynchronization therapy implantation, which resulted in pneumopericardium and pneumothorax.

CONCLUSION

Although pneumopericardium caused by atrial lead perforation can spontaneously resolve with conservative treatment, as it did in this case, treatment should be decided based on the patient's general condition and lead performance.

Rare atypical presentation of a polymicrobial gastropericardial fistula

We present the unique case of a gastropericardial fistula with a rare, delayed presentation in a man in his 70s. Relevant surgeries include Watchman Left Atrial Appendage Closure device placement 1 year prior to arrival and gastric bypass surgery 20 years prior to arrival. The patient presented to the emergency department with weakness, diarrhoea and left knee pain. He was admitted for cellulitis of the left lower extremity, prosthetic septic arthritis of the left knee and group G streptococcus bacteraemia. His hospital course was complicated by acute chest pain and dyspnoea. Imaging revealed pneumopericardium. Oesophagogastroduodenoscopy visualisation confirmed the diagnosis of gastropericardial fistula. The patient could not be transferred to a tertiary centre for definitive management because of the effect of the COVID-19 pandemic on tertiary hospital volumes. After pericardial drainage and administration of antimicrobials without improvement, the patient was discharged to hospice care at his request and died 1 day after discharge.

Lung Cancer-Related Pneumopericardium

N/a.

Pneumopericardium, pneumomediastinum and surgical emphysema in spontaneous pneumothorax

Spontaneous pneumothorax leading to pneumomediastinum, pneumopericardium and surgical emphysema is a benign condition. Progression to the development of epidural pneumatosis is rare. We report a 19-year-old man who presented with dyspnoea and swelling of the chest wall following a bout of cough. Bilateral subcutaneous emphysema was palpated on the anterior chest wall from the sternum to the midaxillary regions. His chest X-ray revealed subcutaneous emphysema and pneumopericardium. His computed tomography of the thorax to rule out life-threatening conditions revealed bilateral subcutaneous emphysema, pneumomediastinum, pneumo-pericardium and pneumothorax. He was transferred to the intensive care unit. An intercostal drainage tube was inserted in the left pleural cavity. The patient was followed up with repeat chest X-rays. The patient's symptom got relieved and was discharged after day 9. Diagnosis of pneumomedia-stinum may not be as lamentable as it is seen. Close cardio-pulmonary monitoring is mandatory for complications and accompanying conditions. Most patients with uncomplicated spontaneous pneumomediastinum respond well to oxygen and conservative management. In this case, the patient's symptoms and severe tachypnoea prompted the insertion of an intercostal drainage tube.

A Rare Evolution to Pneumopericardium in Patient with COVID-19 Pneumonia Treated with High Flow Nasal Cannula

Infection with severe acute respiratory syndrome coronavirus 2 causes coronavirus disease 2019 (COVID-19) which was revealed an official pandemic by the World Health Organization on 11 March 2020. The current pandemic, the third of this decade, is the worst in terms of suffering and deaths related. COVID-19 represents an unprecedented challenge for medical communities and patients around the world. High-resolution computed tomography of the chest (HRCT) is a fundamental tool in both management and diagnosis of the disease. Imaging plays an essential role in the diagnosis of all the manifestations of the disease and its complications and the correct use and interpretation of imaging tests are essential. Pneumomediastinum has been reported rarely in COVID-19 patients. We were one of the first groups to share our experiences in uncommon parenchymal complications of COVID-19 with spontaneous pneumothorax and pneumomediastinum, but also with new-onset bronchiectasis and cysts. A finding of pneumopericardium is also unusual. We hereby report a rare case of spontaneous pneumopericardium in a patient with COVID-19 pneumonia treated only with a high-flow nasal cannula (HFNC).

Pneumopericardium and pleural effusion: a rare complication of paediatric pericardiocentesis

Pneumopericardium is a rare complication of pericardiocentesis (PC), occurring as a result of either a direct pleuropericardial communication or a leaky drainage system. Pneumopericardium is often self-limiting; however, physicians should be aware of this complication as it may progress to tension pneumopericardium, which requires immediate recognition and management. PC has been associated with pneumothorax, pneumomediastinum or subcutaneous emphysema, but the association with pleural effusion has been less reported. The authors present the case of a 14-year-old healthy boy who developed post-PC pneumopericardium and pleural effusion, a rare association reported in the literature. The diagnosis of this potential life-threatening event was made using readily available complementary diagnostic methods, such as transthoracic echocardiography and chest X-ray.

Iatrogenic Pneumopericardium During Pericardiocentesis

Iatrogenic pneumopericardium after pericardiocentesis due to accidental leakage from the side port of the sheath has been reported in the literature. In the present case, it occurred during passage of the guidewire. Every step needs to be done meticulously. The patient should be advised not to take a deep breath during the puncture.

Spontaneous pneumomediastinum, pneumopericardium and subcutaneous emphysema in a case of interstitial pneumonia with autoimmune features

Spontaneous Pneumomediastinum (SPM) is a benign, self-limiting but potentially fatal condition specially in underlying pulmonary disease. Spontaneous pneumomediastinum is rarely associated with connective tissue related interstitial lung disease. We report a patient of interstitial pneumonia with autoimmune features who presented with acute onset breathlessness and was diagnosed to have spontaneous pneumomediastinum, pneumopericardium, and subcutaneous emphysema. This condition are easily diagnosed by clinical findings like Hamman's crunch and plain chest radiographs in cases with normal underlying lungs. In cases of extensive pulmonary fibrosis like Interstitial Lung Diseases both clinical findings and Plain chest radiographs can be inconclusive. CT of thorax is the gold standard diagnostic modality. Pneumopericardium rarely leads to cardiac tamponade, which requires immediate surgical intervention. We conclude that every case of acute onset breathlessness in a known case of interstitial lung disease may not necessarily be an exacerbation of the underlying lung condition. Physicians need to have a high index of suspicion while treating patients of interstitial lung disease. CT thorax is gold standard diagnostic modality especially in presence of fibrotic lung diseases.

[Asymptomatic pneumopericardium in a young male cannabis smoker]

Pneumopericardium is a potential complication to frequent cannabis smoking due to barotrauma of the airways caused by forceful coughing and Valsalva's manoeuvre. This is a case report of a 27-year-old man, who had a daily consumption of cannabis and presented with abdominal pain and nausea consistent with cannabinoid hyperemesis syndrome. A CT scan revealed an asymptomatic isolated minor pneumopericardium. The patient was observed, and no intervention was needed. At an outpatient control ten days later the pneumopericardium had spontaneously resolved.

[An airy feeling]

A 65-year-old man, diagnosed with bronchus cancer metastasized to the brain and lymph nodes, was seen at the emergency department. He complained of 'an airy feeling' within the left side of his thorax. Imaging revealed a pneumopericardium, probably caused by a fistula between the primary tumour and the pericardium.

Pneumomediastinum and pneumopericardium as rare complications after retroperitoneal transpsoas lateral lumbar interbody fusion surgery: A case report

RATIONALE

Pneumomediastinum and pneumopericardium refer to conditions in which air exists within the mediastinum and pericardium, respectively. There is the communication between the mediastinum, pericardium, and retroperitoneum. We present the first report of rare complications (pneumomediastinum and pneumopericardium) after retroperitoneal transpsoas lateral lumbar interbody fusion (LLIF) surgery.

PATIENT CONCERNS

A 73-year-old female who underwent LLIF using the retroperitoneal approach complained of dysphagia but no other abnormal symptom after surgery.

DIAGNOSIS AND INTERVENTIONS

A plain chest radiograph (CXR) taken immediately the following surgery did not show any unusual findings but CXR took on postoperative day (POD) 1 indicated pneumopericardium and pneumomediastinum with abnormal air density along the pericardium and mediastinum with subdiaphragmatic air density. A chest computed tomography revealed bilateral pleural effusion and abnormal air density (pneumopericardium and pneumomediastinum) connected to a large amount of air around the aorta and retroperitoneal space (pneumoretroperitoneum).

OUTCOMES

The patient complained of no unusual symptom and the CXR on POD 6 indicated that no air density surrounding the mediastinum and pericardium was found.

LESSONS

Pneumomediastinum and pneumopericardium should be considered possible complications of LLIF using retroperitoneal transpsoas approach. Such a condition may progress to fatal conditions without early recognition and rapid management.

Pneumopericardium, pneumomediastinum, and pneumorrachis complicating acute respiratory syncytial virus bronchiolitis in children

OBJECTIVE

We report 2 children with Respiratory Syncytial Virus (RSV) infection complicated with spontaneous pneumopericardium (PP) and pneumomediastinum (PM), one also associated with pneumorrhachis (PR).

PATIENTS AND METHODS

Two previously healthy children presented with fever, violent dry cough, dyspnea, and tachypnea. Chest X-ray and CT scans showed sizeable PP and PM in both patients. One of them also presented PR. Children were initially treated with intravenous antibiotics, antipyretics, and a cough sedative. Because of worsening of respiratory distress syndrome, children underwent helmet-delivered CPAP with oxygen supplementation. The patients' clinical conditions quickly improved and they were discharged in good conditions.

RESULTS

Pathogenetic mechanism of spontaneous PP and PM complicating RSV infection could be related to the cough, causing intrathoracic pressure increase and rupture of alveoli near the mediastinal pleura. Nevertheless, RSV seems to play a role in facilitating such complications, attenuating the cough threshold in infected children.

CONCLUSIONS

RSV bronchiolitis can lead respiratory and systemic consequences, so their prompt recognition is essential to establish a fast and adequate therapy, especially control of cough and respiratory distress syndrome treatment.

Iatrogenic Pneumopericardium After Pericardiocentesis

A 65-year-old patient underwent pericardiocentesis for cardiac tamponade after radiofrequency ablation for ventricular tachycardia. Subsequent to stabilization, the patient developed pneumopericardium, which was detected in the catheterization laboratory and managed successfully by pericardial aspiration.

A fatal complication of an incarcerated diaphragmatic hernia: pyo-pneumopericardium due to a gastro-pericardial fistula Case report and literature review

INTRODUCTION

The pyo-pneumopericardium is a very rare complication of an incarcerated diaphragmatic hernia. Usually, it depends on the existence of a gastropericardial fistula and, in most cases, it is a deadly complication.

CASE REPORT

We present the case of a 65 year old man who was admitted to our emergency service with clinical signs of septic shock. With the help of the CT scan a pyo-pneumopericardium and incarcerated diaphragmatic hernia was diagnosed. He was subjected to emergency surgical intervention with double approach (thoracic and abdominal), discerning during surgery the existence of a pericardial abscess due to a gastro-pericardial fistula due to an incarcerated diaphragmatic hernia. The gastric fundus was resected with abolition of the gastro-pericardial fistula, evacuation of the pericardial abscess, performing the splenectomy (in order to have a better surgical access) and adequate treatment of the diaphragmatic hernia. Despite the medical efforts, the patient died on the 10th postoperative day due to septic complications. To our knowledge this is the first case reported in the literature of gastro-pericardial fistula complicated with pyo-pneumo-pericardium due to an incarcerated diaphragmatic hernia. In such cases we consider that only by performing a double surgical approach (thoracic and abdominal) we can provide a proper resolution of the case, also based on the objective situation found during surgery, where the splenectomy can provide an easier approach to the diaphragmatic hernia.

KEY WORDS

Diaphragmatic hernia, Gastropericardial fistula, Pyo-pneumopericardium.

A fatal complication of an incarcerated diaphragmatic hernia Pyo-pneumopericardium due to a gastro-pericardial fistula, case report and literature review

A fatal complication of an incarcerated diaphragmatic hernia: pyo-pneumopericardium due to a gastro-pericardial fistula, case report and literature review

INTRODUCTION

The pyo-pneumopericardium is a very rare complication of an incarcerated diaphragmatic hernia. Usually, it depends on the existence of a gastropericardial fistula and, in most cases, it is a deadly complication.

CASE REPORT

We present the case of a 65 year old man who was admitted to our emergency service with clinical signs of septic shock. With the help of the CT scan a pyo-pneumopericardium and incarcerated diaphragmatic hernia was diagnosed. He was subjected to emergency surgical intervention with double approach (thoracic and abdominal), discerning during surgery the existence of a pericardial abscess due to a gastro-pericardial fistula due to an incarcerated diaphragmatic hernia. The gastric fundus was resected with abolition of the gastro-pericardial fistula, evacuation of the pericardial abscess, performing the splenectomy (in order to have a better surgical access) and adequate treatment of the diaphragmatic hernia. Despite the medical efforts, the patient died on the 10th postoperative day due to septic complications. To our knowledge this is the first case reported in the literature of gastro-pericardial fistula complicated with pyo-pneumo-pericardium due to an incarcerated diaphragmatic hernia. In such cases we consider that only by performing a double surgical approach (thoracic and abdominal) we can provide a proper resolution of the case, also based on the objective situation found during surgery, where the splenectomy can provide an easier approach to the diaphragmatic hernia.

Coronary gas embolism during a dive: a case report

INTRODUCTION

A healthy scuba diver presented with a NSTEMI (non-ST segment elevation myocardial infarction), pneumothorax and pneumomediastinum after diving.

CASE REPORT

A 34-year-old woman with no significant medical history presented to the emergency department after an episode of loss of consciousness and seizure-like activity after an uncontrolled ascent during a dive in a freshwater lake at 5,700 feet of altitude. A chest radiograph showed pneumothorax, pneumomediastinum and pneumopericardium. She had septal infarction as indicated by ECG, and elevated troponin. Echocardiogram revealed a mildly depressed left ventricular ejection fraction (LVEF) with apical akinesis. Coronary angiogram showed normal coronary arteries. Hyperbaric oxygen was not given since evaluation occurred 28 hours after the event: The patient had a pneumothorax, and was neurologically normal. She was discharged on angiotensin-converting enzyme inhibitors (ACE-I) and opioids for chest pain. Cardiac function normalized on transthoracic echocardiogram (TTE) two weeks later, but she continued to complain of chest pain that was treated with dihydropyridine calcium channel blockers. She then developed pericarditis confirmed by CMRI, requiring treatment with non-steroidal anti-inflammatory drugs (NSAIDS), colchicine and steroids. Five months after the accident, she was asymptomatic, with excellent exercise function and normal exercise stress echocardiogram.

CONCLUSIONS

Reports of myocardial injury caused by arterial gas embolism from diving are rare. This case shows coronary air embolism complicating pulmonary barotrauma and may be the first report of pericarditis complicating myocardial injury after an AGE.

[Pneumorachis and pneumopericardium after ecstasy use: an uncommon complication]

BACKGROUND

Over the past few years there has been an increase in the use of ecstasy among the Dutch population. A number of complications are associated with this drug, hyperthermia being the most well-known. A less commonly-occurring complication is pneumomediastinum.

CASE DESCRIPTION

A 20-year-old man presented at the emergency department with extensive subcutaneous emphysema, pneumomediastinum, pneumopericardium and pneumorachis (air within the spinal canal), which had developed after visiting a festival. After excluding the most likely causes, it was concluded that it was due to a combination of ecstasy use and intensive activity (dancing). He was managed conservatively and after two days of observation in the ICU the patient fully recovered.

CONCLUSION

This case illustrates a rare complication that seems - indirectly - related to using ecstasy. In most cases conservative treatment is adequate but the presence of pneumopericardium means that given the risk of cardiovascular complications, cardiopulmonary monitoring is essential to trace them.

Pericardioesophageal fistula following left atrial ablation procedure

We present a case of pericardioesophageal fistula formation in a 40 year old male who 23 days after undergoing a repeat ablation procedure for atrial fibrillation developed chest pressure, chills and diaphoresis. After initial labs and tests that demonstrated no evidence for acute myocardial ischemia, the patient underwent CT angiography of the chest. The study revealed pneumopericardium and a pericardial effusion. Suspicion was raised of perforation of the posterior left atrial myocardial wall with injury to adjacent esophagus. Water soluble contrast with transition to barium sulfate esophagram subsequently performed identified a perforation further affirming the postulate of a fistulous communication between the esophagus and pericardium. Transthoracic echocardiogram confirmed pericardial effusion but did not demonstrate myocardial defect. Endoscopic management was preferred and an esophageal stent was placed. Follow up esophagram showed an intact esophageal stent without evidence of extravasation.

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.

Boerhaave's syndrome: a differential diagnosis of acute chest pain following a vomiting illness

Spontaneous oesophageal rupture (Boerhaave's syndrome) is extremely rare in children. Presentation is usually in middle aged men as a result of vomiting following heavy food or alcohol consumption. We describe an unusual case of a 12-year old boy without significant past medical history presenting with acute chest pain following gastroenteritis.

Pneumomediastinum, pneumopericardium, orbital subcutaneous emphysema as consequence of low energy impact facial trauma

Although not an uncommon occurrence from displaced zygomaticomaxillary complex fractures, localized air emphysema tends to resolve without consequence. Nevertheless, when accentuated by nose blowing or other forms of positive pressure soon after trauma, local air emphysema can spread via fascial planes into distant sites.

Subcutaneous emphysema, pneumopericardium, pneumomediastinum and pneumoretroperitoneum secondary to sigmoid perforation: a case report

A 50-year-old woman presented with chronic epigastric abdominal pain and constipation. She underwent diagnostic upper and lower endoscopy for further evaluation. Several hours following the procedure, she developed chest and subcutaneous emphysema of her upper chest, neck, and face. A chest X-ray demonstrated marked subcutaneous emphysema, pneumopericardium, and pneumomediastinum. A CT scan revealed a small leak at the rectosigmoid junction. Because the patient did not have peritoneal signs, she was treated conservatively and discharged on hospital day seven. The complications of both esohagogastroduodenoscoy, and colonoscopy are discussed, with an emphasis on perforations.