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Chest pain and shortness of breath

Our appreciation is extended to Dr. Clark Rogers,
Indiana University Department of Radiology,
for contributing this case.

History:  Chest pain and shortness of breath
On the left are today's PA and lateral CXR. On the right are comparisons from one month ago. Click to enlarge.

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Which choice best depicts the most salient finding(s) in terms of new vs old examination?

Change in heart size.Change in aortic contour.New pleural effusions.New atelectasis.New skeletal abnormality.
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Chest pain and shortness of breath



The new CXR is again shown below. Can you determine the most likely cause for the newly enlarged cardiac size?

Ischemic heart disease.Ventricular aneurysm.Viral cardiomyopathy.Pericardial effusion.Acute renal failure.Click for galleryClick for gallery
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Chest pain and shortness of breath

Here are some CT images to correlate with the CXR examination. Click to enlarge.

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Did you notice on the lateral CXR the epicardial fat (as a lucency) abutting the effusion anteriorly?

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Findings:  New chest radiograph shows significant interval increase in heart size compared to the prior. No focal infiltrates. CT demonstrates new finding of pericardial fluid greater than 2 cm thick and isodense with water. No pleural effusions are present.


Differential diagnosis:

  • Myocardial enlargement
  • Pericardial effusion
  • Pericardial thickening or mass
  • Mediastinal mass
Diagnosis:  Pericardial effusion secondary to rheumatoid arthritis
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Chest pain and shortness of breath


Key points - pericardial effusion:
 

  • Best diagnostic clue is change in size of heart on serial radiographs
  • Normally 15-50 mL fluid in pericardial space.
  • Gold standard for specific diagnosis is pericardiocentesis
  • Echocardiography is best imaging tool for detection; CT best for characterization
  • Most common etiologies are infections, neoplastic, autoimmune, or idiopathic.
  • Most common symptoms are chest pain, palpitations, syncope, dyspnea and light-headedness but is often asymptomatic even with large pericardial effusions if developed over long period of time.
  • Beck's Triad: hypotension, muffled heart sounds and jugular venous distention
  • Treatment generally depends on etiology. In our case with rheumatoid arthritis the patient was treated with corticosteroids.
  • Surgical treatment such as subxiphoid pericardial window or median sternotomy reserved for tamponade or severe symptoms.

References: 

  1. Taken from "Pericardial Disease, malignant and inflammatory" page in statdx.com on 5/31/2011.
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Chest pain and shortness of breath


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