Pneumopericardium is the accumulation of
air in the pericardial space. It is mostly caused
by blunt or penetrating traumas. Rarely, it can
occur due to the fistulization of nearby organs,
tuberculosis and fungal infections, pacemaker
implantation, and pericardiocentesis.[
2,
4] During
pericardiocentesis, pneumopericardium can be caused
by direct pleuropericardial connection or reverse air
leakage from the catheter.[
3] Therefore, the use of
under-water drainage systems may be considered to
prevent the back-flow of air during fluid drainage.
Given the short distance between the pericardium
and the skin, cachectic patients may also develop
pneumopericardium after the removal of the catheter
due to the development of negative pressure during
inspiration.[
3,
5,
6] In the present case, there are two
possible reasons for pneumopericardium: our patient
was thin, and the hub of the pigtail catheter remained
open, which might have caused the air leakage into the
pericardium.
Pneumopericardium can be asymptomatic
or may manifest nonspecific symptoms, such as
palpitations, shortness of breath, and chest and
shoulder pain. The typical auscultatory finding
is the Hamman sign, which is a crackling sound
that can be heard with every cardiac beat. Another
physical finding is the mill-wheel murmur, or
bruit de moulin, which is a succession splash
and traducing shaking movement of the heart
within the pericardial cavity.[1,6] In cases where
pneumopericardium is suspected, imaging should
be performed by echocardiography and radiological
examinations. Echocardiography can demonstrate
two pathognomonic signs: the “air gap sign,” a cyclic
disappearance of the cardiac shape during systole,
coinciding with a cycling appearance of air within
the pericardium during this phase as the volume of
cardiac cavities decreases,[7] and the “swirling bubbles
sign,” representing the presence of an air-fluid
interface with continuous churning movements in
the pericardial cavity due to heart activity, which is
revealed on echocardiography by several tiny bright
echogenic spots in the pericardial sac evoking
micro air bubbles.[5,6,8] The pneumopericardium can easily be diagnosed by chest radiographs, which
reveal a radiolucent rim separating the pericardium
from the heart, called the “continuous diaphragm
sign.”[5,6,8] Chest computed tomography can easily
confirm the diagnosis and is the mainstay of
diagnosis of pneumopericardium in obscure cases.
The tomography clearly demonstrates the air-fluid
level in the pericardial space, as well as informing
about the cause and associated pathologies.[9]
The clinical course in pneumopericardium is
highly variable and depends on the etiology, the
amount, and the rate of air accumulation. Just as
in fluid buildup, a small amount of fast-collected
(60 mL) air can cause hemodynamic deterioration,
while more slowly collected (500 mL) air can be
better tolerated.[1] Iatrogenic pneumopericardium is
usually benign. Spontaneous resolution can occur
within a few days of follow-up. Bed rest should
be exercised in these patients, and hemodynamic
parameters should be closely monitored. The patient
should be screened until resolution is observed on
chest X-ray and echocardiography.[3,5] The most
feared and fatal complication is the development of
tension pneumopericardium. Drainage should be
performed without delay when there is hemodynamic
deterioration or an increase in the amount of air
or fluid on imaging methods. Drainage can be
percutaneously or surgically performed depending
on the urgency of the case and the etiology. Surgical
treatment is considered if there is direct fistulization
with an organ other than the lung or if the fluid is
likely to recollect.[3,6]
In this case report, since secondary causes of
chylopericardium were ruled out, the patient was
considered to have primary idiopathic chylopericardium.
Treatment of this disease consists of a diet poor in fatty
acids, opening a pericardial window, and, if necessary,
thoracic duct ligation.[10]
In conclusion, iatrogenic pneumopericardium,
a rare complication of pericardiocentesis, usually
has a good prognosis and does not require specific
treatment. However, it rarely progresses to pericardial
tamponade, which may require percutaneous or
surgical intervention.
Patient Consent for Publication: A written informed
consent was obtained from patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Conflict of Interest: The author declared no conflicts of
interest with respect to the authorship and/or publication of
this article.
Funding: The author received no financial support for the
research and/or authorship of this article.
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