Epipericardial Fat Pad Necrosis—A Rare Cause of Chest Pain in an Adolescent

Abstract

Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain reported in approximately 40 cases. This diagnosis mimics a myocardial infarction, pulmonary embolism, or pericarditis; however, the cardiac enzymes and electrocardiogram are usually normal. We present the first reported case of epipericardial fat necrosis in an adolescent.

Epipericardial Fat Necrosis: A Case Report and a Review of the Literature

“…Slightly elevated D-dimer, CRP, and/or white blood cell count is relatively common in EFN, 2 , 6 - 10 which also is true for most of its differentials. Echocardiogram is usually normal, but nonspecific ECG changes such as ST-T wave abnormalities are reported.…”

“…In the few cases performed, TTE in EFN are reported as normal, despite a positive chest CT. 3,6,9,10,22 It has been suggested that failure to identify the epipericardial fat pad necrosis in EFN might be due to lung artefacts or the patient being unable to position himself optimally for the examination due to pain. 6 An exception was a report where both transthoracic and transoesophageal echocardiography revealed a paracardiac mass with a calcified rim, suggestive of chronic EFN. 27 In the EDs, point-of-care ultrasound (POCUS) is rising as a clinical tool allowing immediate patient-care decisions, often using a linear probe assessing symptoms from the chest.…”

Mediastinal Fat Necrosis

“…4 A few cases in pediatric patients have been reported in the medical literature. [5][6][7] Mediastinal fat necrosis may be underdiagnosed in children because CT is not performed routinely in the diagnostic workup of chest pain. 6 Pediatric patients who have the clinical features of musculoskeletal chest pain and no other relevant findings do not require additional evaluation or referral.…”

“…[5][6][7] Mediastinal fat necrosis may be underdiagnosed in children because CT is not performed routinely in the diagnostic workup of chest pain. 6 Pediatric patients who have the clinical features of musculoskeletal chest pain and no other relevant findings do not require additional evaluation or referral. 8 Mediastinal fat necrosis usually manifests with acute pleuritic chest pain in previously healthy individuals and can mimic acute cardiopulmonary processes.…”

“…2,7 Conservative treatment is indicated, and nonsteroidal anti-inflammatory drugs are usually sufficient to relieve the symptoms. 1,2,[4][5][6][7] In cases of diagnostic uncertainty, follow-up imaging examinations can be performed to document the expected lesion shrinkage or disappearance. 7 A confident diagnosis based on imaging findings may help to preclude unnecessary invasive procedures, and conservative symptomatic treatment is the recommended Figure. Contrast-enhanced CT images (soft-tissue window) in the A, axial and B, coronal planes showing an ovoid mediastinal fatty lesion (arrow) in the left cardiophrenic space, measuring 1.5 Â 1.4 Â 0.9 cm, demarcated by a soft-tissue attenuation ring, with intrinsic and surrounding dense stranding, and thickening of the adjacent pericardium.…”