A previously well 47‐year‐old woman presented with a 4‐week history of non‐productive cough and lethargy without weight loss, orthopnoea or exertional dyspnoea. She was normotensive and a non‐smoker.
Clinical examination was unremarkable, and no lymphadenopathy was detected. Routine blood tests including inflammatory markers were normal. The electrocardiogram showed sinus rhythm with non‐specific T wave changes in the lateral chest leads. The chest radiograph showed an enlarged, globular cardiac silhouette mimicking pericardial effusion. No previous chest radiographs were available for comparison.
Transthoracic echocardiography revealed an extensive homogeneous mass surrounding the heart, with no evidence of compression or left ventricular hypertrophy. Computed tomography and magnetic resonance (MR) imaging showed an extensive fat density mass enveloping the heart and arising from the epicardium, maximally 5.8 cm in radius (panels A–C; arrows show extensive (5.8 cm) epicardial lipoma surrounding the heart). There was no associated mediastinal lymphadenopathy.
Over three months she developed progressive exertional dyspnoea with development of restrictive respiratory physiology: forced expiratory volume in 1 second (FEV1) 1.26 litres (56% predicted), forced vital capacity (FVC) 1.56 litres (59% predicted). A repeat MR scan suggested right heart compression. She underwent surgical resection of a massive lobulated fatty tumour via median sternotomy, with resolution of her symptoms. Histological examination revealed mature adipocytes typical of a benign lipoma.
Epicardial lipomata can mimic pericardial fluid on plain radiographs of the chest. These tumours are rare, accounting for 10% of primary cardiac tumours, and often clinically silent. Proximity of the tumour to the coronary arteries may limit resection. This case is unusual for the rapid progression of symptoms caused by cardiac and pulmonary compression.
