Full text of DOI:10.1177/021849230000800117

ACrAdSaE STUDY
SPONTANEOUS PNEUMOPERICARDIUM AND PNEUMOMEDIASTINUM
SPONTANEOUS
PNEUMOPERICARDIUM AND
PNEUMOMEDIASTINUM
Kemal Arda, MD, Olcay Eldem, MD1,
Ahmet Sig˘irci, MD, Fikri Özgür Özkan, MD
Department of Radiology
1Department of Cardiology
˙
Türkiye Yüksek Ihtisas Hospital
Ankara, Turkey
ABSTRACT
A 20-year-old man with a 5-year history of ulcerative colitis presented with sudden
chest pain and diarrhea. Chest radiography, echocardiography, and computed
tomography demonstrated pneumomediastinum and pneumopericardium. The
condition resolved completely after one week.
(Asian Cardiovasc Thorac Ann 2000;8:59–61)
cardiography revealed normal sinus rhythm. Chest
INTRODUCTION
radiography showed a double-contoured cardiac silhouette
(Figure 1). Esophagograms with water-soluble contrast
medium were taken to eliminate the esophageal
pathologies; these were normal (Figure 2). Computed
tomography of the chest and echocardiography confirmed
pneumopericardium and pneumomediastinum (Figure 3).
Pneumopericardium, the collection of air or gas in the
pericardium, is a serious condition that may become life
threatening. Pneumomediastinum is the collection of air
or gas in the mediastinum. Spontaneous pneumoperi-
cardium and pneumomediastinum, sometimes called
pericardial-mediastinal emphysema, is a very rare condi-
tion with a multitude of causes: parturition, pulmonary
barotrauma, severe cough, asthma, cocaine inhalation,
chlorine gas exposure, emesis, and athletics.1 We describe
a case of spontaneous pneumopericardium and pneumo-
mediastinum with unknown etiology, which resolved
completely.
The pneumopericardium persisted for one week, then
resolved completely. In the following 3 weeks, the patient
was asymptomatic, capable of normal physical activity,
and the chest radiograph was normal.
DISCUSSION
Pneumopericardium was first described by Bricketeau in
1844, who named the classical pericardial sound associated
with this disorder “bruit de moulin” (water-wheel sound).2
Since then, the etiology of pneumopericardium has been
the subject of several case reports and reviews. The causes
CASE REPORT
A 20-year-old man was admitted to hospital with sudden
retrosternal pain and diarrhea. He had a history of
ulcerative colitis for 5 years. His blood pressure was
130/80 mm Hg, pulse 80 beats·min–1 and regular, described in the literature were classified according to
respiration 12 breaths·min–1 and temperature 36.5°C. etiology.3 (1) Iatrogenic, including thoracentesis, endo-
There were generalized bronchovesicular sounds over tracheal intubation, esophagoenterostomy, postcathe-
terization of esophageal webs, post-sternal bone marrow
aspiration. In preterm infants during treatment of idiopathic
respiratory distress syndrome, the use of positive-pressure
both lungs. Cardiac auscultation was unremarkable.
Laboratory findings were within normal limits except for
an erythrocyte sedimentation rate of 38 mm·h–1. Electro-
For reprint information contact:
Kemal Arda, MD Tel: 90 312 481 0150 Fax: 90 312 312 4122 email: kemalarda@yahoo.com
Ilker 1. Cadde 14/2, Dikmen, Ankara 06460, Turkey.
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SPONTANEOUS PNEUMOPERICARDIUM AND PNEUMOMEDIASTINUM
Arda
ventilation is an important cause. (2) Trauma, penetrating pneumomediastinum alone may mimic those of
or blunt, including foreign body aspiration. (3) Pericarditis pneumopericardium, so radiographic evidence of air in
and production of gas caused by gas-forming organisms. the pericardial space is the pathognomonic sign that must
It can also occur by direct extension of an inflammatory be present to establish conclusively a diagnosis of
process such as lung, liver, or subphrenic abscess. (4) pneumopericardium.
Fistula formation between the pericardium and air-
containing structures such as the gastrointestinal tract,
the pleural cavity and the bronchial tree.
Spontaneous pneumomediastinum and pneumoperi-
cardium are almost always self-limiting. Treatment may
not be required unless a large amount of air is present or
The rise in the intraalveolar pressure above atmospheric if there is tension pneumopericardium.4 Most patients
pressure is important in the pathophysiology of pneumo- recover spontaneously within one or two weeks, as in this
pericardium and pneumomediastinum. The alveoli then case.1
rupture and air moves to the hilar area, mediastinum, and
through the pericardial reflection on the pulmonary vessels
into the pericardial cavity. The parietal pericardium is
reflected on the visceral pericardium near the ostia of the
pulmonary veins, the weakest histological area.3
Pneumopericardium may be symptomatic or asympto-
matic. The classical symptoms are dyspnea and precordial
pain. Other symptoms depend on the underlying etiology.
If a large quantity of air is present, the percussion note
over the pericardium may become tympanic and the heart
sounds may be metallic in quality, accompanied by a
splashing sound of high frequency (bruit de moulin).
However, when only a small amount of air is present,
cardiac examination may be normal, as in this case. The
chest radiograph confirmed the diagnosis. The gas did
not rise above the upper limit of the pericardium in the
erect position, differentiating pneumopericardium from
pneumothorax or pneumomediastinum. There is also a
strip of soft tissue consisting of the pericardium with its
associated soft tissue structures.3 The symptoms of
Figure 2. Contrast esophagogram showing no pathologic changes.
Figure 1. The chest radiograph showing a double contour on the left
Figure 3. Computed tomography scan showing the appearance of the
side of the cardiac silhouette.
pneumopericardium at the anterior side of the right ventricle.
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SPONTANEOUS PNEUMOPERICARDIUM AND PNEUMOMEDIASTINUM
3. Katzir D, Klinovsky E, Kent V, Shucri A, Gilboa Y.
Spontaneous pneumopericardium: a case report and review
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accompagné d’un bruit de fluctuation perceptile á l’oreille.
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