Pyopneumopericardium: A Case of a Broncho-Pericardial Fistula From a Cavitary Lung Mass

Abstract

INTRODUCTION: Pneumopericardium, or air in the pericardial space, most often results from associated trauma. Less commonly, it is associated with disease processes in contiguous organs. Rare cases of tension pyopneumopericardium have been described (1). CASE PRESENTATION:A 57-year-old female with a history of an enlarging cavitary lung lesion of unknown etiology for one year, complicated by recurrent P. Aeruginosa pneumonia presented to the emergency room with acute on chronic chest pain and shortness of breath. On admission, she was toxic appearing with decreased breath sounds over the left lung field and tachycardic. Initial laboratory evaluation showed a WBC of 19K with 87% neutrophils and lactic acidosis of 2.6. A CT scan noted the previously described cavitary mass in left hemithorax measuring 10 x 7 x 9 cm and a pericardial effusion measuring up to 2.9 cm. Blood cultures grew MDR P. Aeruginosa for which she was started on appropriate antibiotics. On hospital day 2, she developed atrial fibrillation and was transferred to the cardiac intensive care unit. While undergoing an urgent pericardiocentesis which demonstrated frank pus, she experienced massive hemoptysis with subsequent cardiac arrest requiring mechanical ventilation. Pericardial fluid also grew MDR P. Aeruginosa. On hospital day 8, air was noted in the pericardial drain requiring frequent emptying. The patient subsequently developed tamponade physiology with increasing vasopressor requirements with accumulation of air in the pericardial drain. Review of the CT scan noted a fistulous tract from the cavitary lesion to the pericardium. Given the patient's poor prognosis, family elected to withdraw care. Pathology from a chest wall biopsy yielded poorly differentiated squamous cell carcinoma.DISCUSSION: A limited number of cases of pyopneumopericardium as a cause of tension pneumopericardium have been described. To our knowledge, there have been no cases of tension pneumopericardium associated with squamous cell carcinoma and P. Aeruginosa pericarditis. Tension pneumopericardium is an emergent condition. Prompt recognition, surgical intervention and antimicrobial therapy is important in patients with pyopneumopericardium, though unfortunately the majority of documented cases have resulted in mortality (2). In the above-described patient, she developed tension pneumopericardium following pericardiocentesis and mechanical ventilation leading to rapid clinical deterioration. Given her advanced disease state, therapeutic interventions were limited at the time of diagnosis. These complications are often unavoidable in the acute clinical setting when patients require urgent or emergent procedures and interventions.CONCLUSIONS: This case illustrates the poor clinical outcomes associated with pyopneumopericardium and the difficult task of early recognition in a patient with multiple acute medical conditions.

Complicated Iatrogenic Pneumopericardium in a Patient With Suspected Multiple Myeloma

“…The pneumopericardium seen in our case is likely due to a leaky drainage system, rather than a pleuro-pericardial communication, leading to the entrance of air into the pericardial sac. Patients with a puncture or fistulous tract-related pneumopericardium commonly develop life-threatening complications as well as evidence of recurrent pneumopericardium despite repeat manual evacuation of air from the pericardial sac [ 6 , 7 ]. If a leaky drainage system is suspected as a potential cause of pneumopericardium, immediate recognition and treatment of this rare complication are essential.…”

“…[ 4 ] Some cases may require chest CT to evaluate pneumopericardium size and to rule out causes like fistulous communications between the esophagus or lungs as well as proof of other injuries that may lead to this rare complication [ 8 , 10 , 11 ]. In addition, echocardiographic findings that may suggest a pneumopericardium include an air gap sign where the image disappears when the heart contracts during systole (Supplemental Video 3 ), absence of an image (Supplemental Video 4 ), or a swirling bubble sign where multiple bright echoes pile up to form a rectilinear line which corresponds to the air-fluid level (Supplemental Video 5 ) [ 6 , 12 ].…”