Case of the Day(sm)

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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.

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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Case of the Day(sm)

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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.

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Case of the Day(sm)

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Chest pain and shortness of breath

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

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

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Case of the Day(sm)

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Chest pain and shortness of breath

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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Case of the Day(sm)

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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: