Pneumopericardium Associated with Bronchogenic Carcinoma* Ronald D. Harris, M.D. 00 and Anthony I. Kostiner, M.D.
A case of pneumopericardium associated with primary bronchogenic carcinoma is reported. This association between bronchogenic carcinoma and pneumopericardium has not been reported. The roentgenographic features of pneumopericardium are discussed.
P
neumopericardium occurring in infants is a wellrecognized entity as evidenced by several recent articles. 1·2 Its occurrence in the adult is still a rare enough phenomenon to stimulate case reports. Although an association of this entity with bronchogenic carcinoma has been mentioned as a cause of pneumopericardium, we have been unable to find a previous case report in our review of the literature. CASE REPoRT
A 31-year-old Caucasian seaman presented in November 1971 with acute onset of left pleuritic chest pain and nonproductive cough. The patient had been smoking two packs of cigarettes per day for many years. A chest radiograph at that time showed the presence of a mass in the left inferor hilum and collapse of the anteromedial basal segment of the left lower lobe ( Fig I ) . The patient was thought to have pneumonia clinically and was treated with antibiotics. The patient next returned in April 1972 because of hemoptysis and a nontender subcutaneous lump on his left forearm. Chest radiographs showed an increased amount of left lower lobe collapse as well as a left pleural effusion. Spuh1m cytolozy was suspicious for a squamous cell carcinoma, and biopsy of the forearm lesion showed metastasis of well-differentiated squamous cell carcinoma. In March 1973, he developed bilateral ankle edema and was treated with diuretics. A chest radiograph at that time showed changes which were felt to represent necrotic hunor in the left lower lobe adjacent to the heart, and changes compatible with a pericardial effusion. The patient returned on April 4, 1973 with continued ankle edema but no chest symptoms other than his chronic nonproductive cough . Chest radiographs done at that time showed the presence of pneumopericarditun ( Figs 2 and 3). The patient left the hospital and was found at home in a collapsed state the next morning. He was pronounced dead on arrival at the hospital.
+-7Z
FIGURE I. Left lateral view shows the tumor mass in the inferior hilum (arrow) associated with the localized atelectasis. have been well discussed in previous articles 7 • 8 and will not be commented on in this report. The roentgenographic findings are striking in pneumopericardium. The parietal pericardium is visible as a bulging curvilinear band of increased density separated
DISCUSSION
The etiology of pneumopericardium has been classified into four major groups 3 - 5 : ( 1) iatrogenic, ( 2) pericarditis, ( 3) fistula formation between the pericardium and an adjacent air-containing organ, and ( 4) trauma. 6 The pertinent clinical findings and modes of therapy •From the Departments of Radiology, US Public Health Service Hospital and University of Washington ( RDH) and Virginia Mason Clinic ( AIK) Seattle. 00 Present address: University of California at San Diego. Reprint requests: Dr. Harris, Department of Radiology, University Hospital, San Diego 92103
CHEST, 67: 1, JANUARY, 1975
FIGURE 2. Postero-anterior view on April 4, 1973 showing the thickened parietal pericardium separated from the heart by a large amount of air within the pericardial sac.
PNEUMOPERICARDIUM ASSOCIATED WITH BRONCHOGENIC CARCINOMA 115
Pediatrics 47 :634-635, 1971 3 Rigler LG: Pneumopericardium. JAMA 84:504-506, 1925 4 Shackelford RT : Hydropneumopericardium. JAMA 96: 187-191, 1931 5 Toledo TM, Moore WL, Nash DA, et al: Spontaneous pneumopericardium in acute asthma. Chest 62: 118-120, 1972 6 Meyer HW : Pneumopyopericardium. J Thorac Cardiovasc Surg 17:62-71, 1948 7 Dassel PM, Kirsh IE : Nontraumatic pneumopericardium and pyopneumopericardium-Report of two cases. Radiology 63 :346-352, 1954 8 Maurer ER, Mendex FL Jr, Finklestein M, et al : Cardiovascular dynamics in pneumopericardium and hydropericardium. Angiology 9:176-197, 1958
Scleroderma Heart Disease with Slow Flow Velocity in Coronary Arteries* M. P. Gupta, M.D.;•• S. Zoneraich, M.D.;t W . ZeitUn, M.D.;! 0 . Zoneraich, M.D.;§ and W. D'Angelo, M.D.§§
FIGURE 3. Left lateral view shows a slight air-8uid level indicating the presence of 8uid as well as air within the pericardia! sac. from the heart by the radiolucent air in the pericardia! sac. The thickness of the pericardium is dependent on the associated inflammation, infiltration or edema. The pericardia) cavity is dilated more to the left than to the right and is limited above by the lower border of the aortic arch. This is a differential point in distinguishing a pneumopericardium from pneumomediastinum in which air dissects beyond the confines of the pericardium. Inferiorly the air may extend to the diaphragm. In the presence of fluid, a horizontal air-fluid level is present (Fig 3) in any body position. Decubitus films will show a rapid shift of the air within the pericardia) sac. This is another differentiating feature from pneumomediastinum. Dassel and Kirsch 7 report that fluoroscopically the heart pulsations are usually vigorous in amplitude. The mechanism of this increased amplitude is thought to be caused by a loss of the normal dampening effect of the pericardium and pleura when separated from the heart by air in the pericardia) space. This allows the wall of the myocardium to be seen silhouetted against the air and the movements more easily seen. If fluid is present the pericardia) surface appears to quiver because of the waves produced by the cardiac motions. In this case we have presented a patient who developed a bronchopericardial fistula secondary to a bronchogenic carcinoma, which had invaded the pericardium. The resultant pneumopericardium produced a sudden hemodynamic collapse and a rapid death. REFERENCES
Loftis JW, Susen AF, Marcy JH, et al: Pneumopericardium in infancy. Am J Dis Child 103.61-65, 1962 2 Markarian M, Ablow RC : Neonatal pneumopericardium.
116 GUPTA ET AL
A young woman with sclerodenna heart disease is presented. Complete work-up including hemodynamic studies revealed biventricular dysfunction, left ventricular hypokinesia and nonnal coronary arteries with slow flow velocity in coronary arteries. This finding, though not diagnostic, is consistent with small vessels disease secondary to sclerodenna. Favorable prognosis in our patient on medical management is encouraging. No conclusions can be drawn on the basis of one patient. Further work is warranted in sclerodenna patients with cardiomegaly to define the status of the myocardial microcirculation and its possible role in their prognosis.
S
cleroderma is a systemic disorder of unknown etiology characterized by excessive proliferation of connective tissue and widespread vascular lesions involving mainly the skin, gastrointestinal tract, lung, heart and kidneys. Associated immunologic abnormalities are also present. Pathologic involvement of the heart include acute and chronic pericarditis, myocardial fibrosis and intimal thickening of small coronary vessels.1 • 3 In this paper, we present a patient with scleroderma •From the Department of Medicine, Division of Cardiology, Queens Hospital Center, the Long Island Jewish/Hillside Medical Center Affiliation, State University of New York, Medical School at Stony Brook and the Department of Medicine, Division of Rheumatology, Queens Hospital Center, Catholic Medical Center Affiliation, Jamaica, New York. 00 Physician-In-Charge Cardiac Catheterization Unit; Assis1 tant Professor of Meaicine. tHead, Division of Cardiology; Associate Professor of Medicine. !Fellow, Department of Cardiology. §Associate Attending in Medicine and Cardiology; Associate Professor of Medicine. §§Director of Medicine, Catholic Medical Center Affiliation; Associate Professor of Medicine. Reprint requests: Dr. Gupta, HiUside Division, Long Island Jewish-Hillside Medical Center, Glen Oaks, New York 11004
CHEST, 67: 1, JANUARY, 1975
A case of pneumopericardium associated with primary bronchogenic carcinoma is reported. This association between bronchogenic carcinoma and pneumopericardium has not been reported. The roentgenographic features of pneumopericardium are discussed.
P
neumopericardium occurring in infants is a wellrecognized entity as evidenced by several recent articles. 1·2 Its occurrence in the adult is still a rare enough phenomenon to stimulate case reports. Although an association of this entity with bronchogenic carcinoma has been mentioned as a cause of pneumopericardium, we have been unable to find a previous case report in our review of the literature. CASE REPoRT
A 31-year-old Caucasian seaman presented in November 1971 with acute onset of left pleuritic chest pain and nonproductive cough. The patient had been smoking two packs of cigarettes per day for many years. A chest radiograph at that time showed the presence of a mass in the left inferor hilum and collapse of the anteromedial basal segment of the left lower lobe ( Fig I ) . The patient was thought to have pneumonia clinically and was treated with antibiotics. The patient next returned in April 1972 because of hemoptysis and a nontender subcutaneous lump on his left forearm. Chest radiographs showed an increased amount of left lower lobe collapse as well as a left pleural effusion. Spuh1m cytolozy was suspicious for a squamous cell carcinoma, and biopsy of the forearm lesion showed metastasis of well-differentiated squamous cell carcinoma. In March 1973, he developed bilateral ankle edema and was treated with diuretics. A chest radiograph at that time showed changes which were felt to represent necrotic hunor in the left lower lobe adjacent to the heart, and changes compatible with a pericardial effusion. The patient returned on April 4, 1973 with continued ankle edema but no chest symptoms other than his chronic nonproductive cough . Chest radiographs done at that time showed the presence of pneumopericarditun ( Figs 2 and 3). The patient left the hospital and was found at home in a collapsed state the next morning. He was pronounced dead on arrival at the hospital.
+-7Z
FIGURE I. Left lateral view shows the tumor mass in the inferior hilum (arrow) associated with the localized atelectasis. have been well discussed in previous articles 7 • 8 and will not be commented on in this report. The roentgenographic findings are striking in pneumopericardium. The parietal pericardium is visible as a bulging curvilinear band of increased density separated
DISCUSSION
The etiology of pneumopericardium has been classified into four major groups 3 - 5 : ( 1) iatrogenic, ( 2) pericarditis, ( 3) fistula formation between the pericardium and an adjacent air-containing organ, and ( 4) trauma. 6 The pertinent clinical findings and modes of therapy •From the Departments of Radiology, US Public Health Service Hospital and University of Washington ( RDH) and Virginia Mason Clinic ( AIK) Seattle. 00 Present address: University of California at San Diego. Reprint requests: Dr. Harris, Department of Radiology, University Hospital, San Diego 92103
CHEST, 67: 1, JANUARY, 1975
FIGURE 2. Postero-anterior view on April 4, 1973 showing the thickened parietal pericardium separated from the heart by a large amount of air within the pericardial sac.
PNEUMOPERICARDIUM ASSOCIATED WITH BRONCHOGENIC CARCINOMA 115
Pediatrics 47 :634-635, 1971 3 Rigler LG: Pneumopericardium. JAMA 84:504-506, 1925 4 Shackelford RT : Hydropneumopericardium. JAMA 96: 187-191, 1931 5 Toledo TM, Moore WL, Nash DA, et al: Spontaneous pneumopericardium in acute asthma. Chest 62: 118-120, 1972 6 Meyer HW : Pneumopyopericardium. J Thorac Cardiovasc Surg 17:62-71, 1948 7 Dassel PM, Kirsh IE : Nontraumatic pneumopericardium and pyopneumopericardium-Report of two cases. Radiology 63 :346-352, 1954 8 Maurer ER, Mendex FL Jr, Finklestein M, et al : Cardiovascular dynamics in pneumopericardium and hydropericardium. Angiology 9:176-197, 1958
Scleroderma Heart Disease with Slow Flow Velocity in Coronary Arteries* M. P. Gupta, M.D.;•• S. Zoneraich, M.D.;t W . ZeitUn, M.D.;! 0 . Zoneraich, M.D.;§ and W. D'Angelo, M.D.§§
FIGURE 3. Left lateral view shows a slight air-8uid level indicating the presence of 8uid as well as air within the pericardia! sac. from the heart by the radiolucent air in the pericardia! sac. The thickness of the pericardium is dependent on the associated inflammation, infiltration or edema. The pericardia) cavity is dilated more to the left than to the right and is limited above by the lower border of the aortic arch. This is a differential point in distinguishing a pneumopericardium from pneumomediastinum in which air dissects beyond the confines of the pericardium. Inferiorly the air may extend to the diaphragm. In the presence of fluid, a horizontal air-fluid level is present (Fig 3) in any body position. Decubitus films will show a rapid shift of the air within the pericardia) sac. This is another differentiating feature from pneumomediastinum. Dassel and Kirsch 7 report that fluoroscopically the heart pulsations are usually vigorous in amplitude. The mechanism of this increased amplitude is thought to be caused by a loss of the normal dampening effect of the pericardium and pleura when separated from the heart by air in the pericardia) space. This allows the wall of the myocardium to be seen silhouetted against the air and the movements more easily seen. If fluid is present the pericardia) surface appears to quiver because of the waves produced by the cardiac motions. In this case we have presented a patient who developed a bronchopericardial fistula secondary to a bronchogenic carcinoma, which had invaded the pericardium. The resultant pneumopericardium produced a sudden hemodynamic collapse and a rapid death. REFERENCES
Loftis JW, Susen AF, Marcy JH, et al: Pneumopericardium in infancy. Am J Dis Child 103.61-65, 1962 2 Markarian M, Ablow RC : Neonatal pneumopericardium.
116 GUPTA ET AL
A young woman with sclerodenna heart disease is presented. Complete work-up including hemodynamic studies revealed biventricular dysfunction, left ventricular hypokinesia and nonnal coronary arteries with slow flow velocity in coronary arteries. This finding, though not diagnostic, is consistent with small vessels disease secondary to sclerodenna. Favorable prognosis in our patient on medical management is encouraging. No conclusions can be drawn on the basis of one patient. Further work is warranted in sclerodenna patients with cardiomegaly to define the status of the myocardial microcirculation and its possible role in their prognosis.
S
cleroderma is a systemic disorder of unknown etiology characterized by excessive proliferation of connective tissue and widespread vascular lesions involving mainly the skin, gastrointestinal tract, lung, heart and kidneys. Associated immunologic abnormalities are also present. Pathologic involvement of the heart include acute and chronic pericarditis, myocardial fibrosis and intimal thickening of small coronary vessels.1 • 3 In this paper, we present a patient with scleroderma •From the Department of Medicine, Division of Cardiology, Queens Hospital Center, the Long Island Jewish/Hillside Medical Center Affiliation, State University of New York, Medical School at Stony Brook and the Department of Medicine, Division of Rheumatology, Queens Hospital Center, Catholic Medical Center Affiliation, Jamaica, New York. 00 Physician-In-Charge Cardiac Catheterization Unit; Assis1 tant Professor of Meaicine. tHead, Division of Cardiology; Associate Professor of Medicine. !Fellow, Department of Cardiology. §Associate Attending in Medicine and Cardiology; Associate Professor of Medicine. §§Director of Medicine, Catholic Medical Center Affiliation; Associate Professor of Medicine. Reprint requests: Dr. Gupta, HiUside Division, Long Island Jewish-Hillside Medical Center, Glen Oaks, New York 11004
CHEST, 67: 1, JANUARY, 1975
