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

Abstract

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. CASE REPORTA 13-year-old male, presented to the Emergency Department complaining of a sudden onset left-sided chest pain for 1 day. The pain was pleuritic in nature and worsened upon lying down. The boy gave history of a mild trauma while playing hockey 2 days prior to his presentation, but no history of fever. Upon examination, he looked uncomfortable and had shallow respirations with normal vital signs. Auscultation of the chest revealed decreased air entry over the left side. Laboratory investigations showed slightly elevated White Blood Cell count (15.00 g/L), (normal range is between 5.0 to 10.0 g/L), minimal increase in Fibrinogen levels (4.88 g/L), (normal range is between 2.0 to 4.0 g/L), and significant increase in C-Reactive Protein (71.20 mg/L), (normal level is less than 10 mg/L). The patient was given Ibuprofen to relieve his pain and a chest x-ray (CXR) was ordered to rule out Pneumonia. Imaging findings:A posterior-anterior (PA) and lateral CXR was performed, PA view showed peripheral opacity involving the lower mid and inferior aspect of the left hemithorax (Figure 1a). The lateral costophrenic angle was clear. No airspace consolidation or pneumothorax. There were no rib changes. On the lateral view, there was a minimal undulation/thickening seen in the lower anterior chest (Figure 1b).

Ectopic epipericardial fat necrosis: a case report

“…The age at which EFN occurs remains unknown [4]; however, it is observed in both men and women and has been reported in children and patients with a transplantation history [5,6]. The most common symptom of EFN is chest pain; other associated symptoms include shortness of breath, dizziness, tachycardia, and cold sweats, although fever and myalgia are not considered classic clinical symptoms [3,7]. Barreto et al [8] reported that EFN with cough and fever was not observed.…”

“…The pathophysiology remains unclear, but hypotheses include hemorrhage owing to destruction of vulnerable vessels by Valsalva maneuvers, such as anger and breath-holding, or acute ischemia of the epicardial fat owing to tortuosity of the vascular stalk [5,9,10]. Another risk factor is the increase in pericardial fat due to obesity, which remains unknown because of the lack of case series [3,5]. Although no characteristic findings have been reported on blood samples, electrocardiograms, or chest radiographs, mild increases in the C-reactive protein level, D-dimer level, and white blood cell counts were reported [11].…”

“…Although the pathophysiology of EFN remains unclear, the spontaneous rupture of adipocytes within epicardial fat has been implicated [3]. This releases inflammatory substances and subsequently causes inflammation of the epicardium [4].…”

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

“…(7) Epipericardial fat necrosis usually presents as a newonset pleuritic chest pain in young healthy patients. (8,9) einstein (São Paulo). 2023;21:1-5…”

“…(13) Typical physical examination findings include tachycardia, tachypnea, and even cardiac friction rub can be found. (8) Potentially serious conditions may be related to these manifestations, such as pericarditis, pneumothorax, pulmonary embolism, acute coronary syndrome, and acute aortic syndrome. (14,15) Epipericardial fat necrosis rarely manifests as electrocardiogram changes (eventually nonspecific repolarization findings).…”