A 40-year-old woman was referred to our department just after an episode of exertional syncope. She had jugular venous distention, clear lung fields, a regular heart rate of 95 beats/min, and a blood pressure of 110/60 mmHg with pulsus paradoxus of 25 mmHg. The patient had been experiencing asthenia, heavy and irregular menses, and inappropriate weight gain during the past 4 months. A preliminary diagnosis of cardiac tamponade was confirmed by echocardiography (Fig. 1), and 2,000 mL of a straw-colored fluid was evacuated by pericardiotomy.
Fig. 1 Transthoracic echocardiography (modified apical 4-chamber view) confirmed a massive circumferential pericardial effusion with “swinging” of the heart.
The post-procedural chest radiograph was dramatically abnormal (Fig. 2), and the heart could no longer be seen on attempted echocardiography. An abnormal air accumulation (thought to be within the pericardial sac) was probably due to negative inspiratory intrathoracic pressure that occurred when the pericardial drainage tubing was inadvertently left open to room air. We checked the aspiration system, and on the same day performed another chest radiograph, which showed no sign of the pneumopericardium. The pericardial tube was removed the next day.
Fig. 2 Post-procedural chest radiograph shows air (arrow) between the cardiac silhouette and the pericardium, which is most likely consistent with a large pneumopericardium rather than a pneumomediastinum.
Hashimoto's hypothyroidism was diagnosed, and replacement therapy with levothyroxin was started. One month later, the chest radiograph showed a normal cardiac silhouette. Thereafter, the patient's overall condition continued to improve, with a progressive normalization of the thyroid function.
Comment
Myxedematous pericardial effusions, which occur in about one third of patients with hypothyroidism, usually do not cause symptoms; these effusions regress slowly with hormonal treatment.
After a pericardiotomy, our patient developed an abnormal cardiac silhouette on chest radiography, and the heart could not be seen on echocardiography. A large pneumopericardium is likely the condition demonstrated on our patient's chest radiograph, although a large pneumomediastinum might produce a similar image.
Pneumopericardium is a very rare disorder and is most commonly the result of blunt chest trauma1; it has also been linked to pericarditis and to pulmonary or digestive fistula,2 and has been seen as a sequela after the administration of the Heimlich maneuver.3
Pneumopericardium is usually asymptomatic, as in our patient, and resolves spontaneously. However, com-plications can occur (for example, tension pneumopericardium), which in turn may lead to unstable he-modynamics.4
Footnotes
Address for reprints: Eloi Marijon, MD, Instituto do Coração, Ave. Kenneth Kaunda 1111, Maputo, Mozambique. E-mail: eloi_marijon@yahoo.fr
Dr. Aubert is now working at the Department of Thoracic and Cardiac Surgery, Pitié Salpetriére Hospital, Paris, France.
References
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