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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 126-128

Pneumopericardium in a patient with pulmonary tuberculosis: A case report and review of literature


Department of Respiratory Medicine, Government Tirunelveli Medical College and Hospital, Tirunelveli, Tamilnadu, India

Date of Submission25-Dec-2021
Date of Decision13-Mar-2022
Date of Acceptance20-Mar-2022
Date of Web Publication12-May-2022

Correspondence Address:
G E Sri Raja Gopal
PG Men's Hostel, Government Tirunelveli Medical College and Hospital, Tirunelveli-627011, Taminadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_49_21

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  Abstract 


Pneumopericardium is defined as the presence of gas in pericardial space. In adults, it may be seen in the context with severe blunt or penetrating chest trauma. The incidence of pneumopericardium is 0.8% and nearly 60% of the cases are due to trauma. A 55-year-old female admitted with the complaints of cough, breathlessness, left-sided chest pain – a case of left secondary spontaneous pneumothorax with the Intercostal drainage tube (ICD) in situ, her computed tomography image revealed pneumopericardium, residual left pneumothorax with ICD tube in the subcutaneous plane. After successful repositioning of ICD tube, pneumopericardium and left pneumothorax both got resolved. Her sputum examination results were positive for Mycobacterium tuberculosis, and she started on Anti-tubercular treatment (ATT). Her condition was gradually improved; the ICD tube was removed and discharged from the hospital in stable condition. On follow-up, both clinical and radiological improvement was there. A severe bout of cough (Macklin effect) and fistulous communication could be the two possible mechanisms for spontaneous pneumopericardium. Treatment of the underlying condition will resolve the pneumopericardium.

Keywords: Pneumopericardium, Pulmonary Tuberculosis, Mechanism, Macklin effect, Diagnosis, Management


How to cite this article:
Raja Gopal G E, Krishnamoorthy K, Pratheeban T J, Mathan E, Rahman O M, Hameed S. Pneumopericardium in a patient with pulmonary tuberculosis: A case report and review of literature. J Assoc Pulmonologist Tamilnadu 2021;4:126-8

How to cite this URL:
Raja Gopal G E, Krishnamoorthy K, Pratheeban T J, Mathan E, Rahman O M, Hameed S. Pneumopericardium in a patient with pulmonary tuberculosis: A case report and review of literature. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 May 16];4:126-8. Available from: http://www.japt.com/text.asp?2021/4/3/126/345086




  Introduction Top


Pneumopericardium is defined as the collection of air/gas in the pericardial cavity. Pneumopericardium most commonly results from trauma to the chest either as blunt or penetration injury. Spontaneous pneumopericardium is a very rare entity and can happen rarely in pulmonary tuberculosis patients with concomitant HIV infection. Iatrogenic causes for pneumopericardium are also reported while performing pericardiocentesis. However, pneumopericardium is largely self-limiting condition and treating the underlying cause will lead to spontaneous resolution.

In this article, we report a case of pneumopericardium in a patient with pulmonary tuberculosis and its management.


  Case Report Top


A 55-year-old female, who is a known case of diabetes mellitus, was admitted to a private hospital with 6 months complaints of cough with purulent expectoration, breathlessness, and pricking type of left-sided chest pain. Her computed tomography (CT) chest showed collection of air within the left pleural cavity over the costal as well as mediastinal aspect and bilateral multilobar consolidation with cavitation changes. She was diagnosed with a case of left secondary spontaneous pneumothorax and left Intercostal drainage tube (ICD) tube insertion was done. She was referred here for further management.

On examination, she was dyspneic and tachypneic and her SpO2 was 97% at room air, PR was 132/min; On auscultation bilateral coarse expiratory crepitations with amphoric breath sound heard over left mammary region. Local examination revealed the presence of subcutaneous emphysema over the left infraclavicular and axillary region. Complete hemogram, chest radiograph, and sputum examination were done. Her sputum results came positive for acid-fast bacillus (AFB); GeneXpert showed the detection of Mycobacterium tuberculosis (MTB) and sensitivity to rifampicin.

Her chest radiograph showed crescentic hyperlucent zone lining the left heart border and ICD tube in situ [Figure 1]. ICD was functioning and air leak of type-E was present. CT chest revealed bilateral multilobar consolidation with cavitation changes; pneumopericardium was noted [Figure 2] and [Figure 3]. Diffuse subcutaneous emphysema with the tip of ICD was observed in the left anterior chest wall within the subcutaneous plane.
Figure 1: Chest radiograph showed crescentric hyper lucent zone lining left heart border and Left Intercostal drainage tube in situ

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Figure 2: CT chest of same patient showed bilateral multilobar consolidation with cavitation changes, Pneumopericardium and subcutaneous emphysema

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Figure 3: CT chest showed pneumopericardium, subcutaneous emphysema and left minimal pleural effusion

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After successful ICD reposition, air leak improved, and chest X-ray showed resolved pneumopericardium and left pneumothorax [Figure 4]. After the air leak settled, ICD was removed, and Chest X-ray showed expansion of the lungs. She was started on ATT Four-drug fixed-dose combinations (4FDC) regimen and other supportive management given. The patient got discharged and advised to continue ATT, diabetic diet. On follow-up, she showed both clinical and radiological improvement [Figure 5], her end intensive phase sputum AFB negative. She started on 3FDC and was advised to come for regular follow-up.
Figure 4: After successful ICD reposition, chest X-ray showed resolved pneumopericardium and left pneumothorax

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Figure 5: On follow up, her chest radiograph showed resolved pneumopericardium, left pneumothorax and some post tuberculous sequelae changes appreciated over right mid zone

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  Discussion Top


Mechanism

Pneumopericardium occurs typically because of breach of pericardium by traumatic or nontraumatic causes. About 60% of cases, the cause for pneumopericardium was chest trauma.[1] This term pneumopericardium was described by Bricheteau in 1844; he named “bruit de Moulin” means “Mill wheel murmur” associated with pneumopericardium.[1]

  • Iatrogenic causes include thoracocentesis, thoracic surgery, endotracheal intubation, sternal bone marrow puncture, and positive pressure mechanical ventilation[1]
  • Noniatrogenic causes can be underlying disease processes such as infected fluid or gas-producing organisms in the pericardial sac, fistulous communication between pericardium and adjacent air-containing structures such as bronchus, esophagus, stomach, and amebic liver abscess[2]
  • Miscellaneous causes include foreign body inhalation, physical exertion, vigorous cough, parturition, and acute asthma.[3]


The possible mechanism of pneumopericardium could either be a fistula between adjacent infected organ and pericardium or a severe bout of cough that causes rise in intra-alveolar pressure above atmospheric pressure; this may lead to rupture of alveoli and the released air moves to the hilar area, mediastinum, and through pericardial reflections on pulmonary vessels (near ostia of pulmonary veins – weakest histological area) into the pericardial cavity – so-called Macklin effect.[4]

Pulmonary tuberculosis, a necrotizing process, could have resulted in fistulous communication between lung and pericardium, leading to pneumopericardium in this patient.


  Clinical features Top


Pneumopericardium may be symptomatic or asymptomatic depending on the quantity of air in the pericardium. The patient with a small pneumopericardium may be asymptomatic, and the cardiac examination may be normal.

In large pneumopericardium, patients may be symptomatic, and a continuous crunching or clicking noise synchronous with the heartbeat heard best in left lateral decubitus position, called as “Hamman's sign.” The most common symptoms are dyspnea and precordial chest pain.[4]

Tension pneumopericardium leading to cardiac tamponade occasionally complicates pneumopericardium. This complication is thought to be caused by ball valve mechanism preventing air from leaving the pericardial space.[5]

Diagnosis

It may be diagnosed incidentally on a chest radiograph, and the gas usually does not rise above the upper limit of the pericardium in erect position, which differentiates pneumopericardium from the pneumomediastinum. Furthermore, on radiographs obtained with the patient in decubitus position, gas in the pericardial sac will shift immediately while gas in the mediastinum will not shift in a short interval between films. Continuous diaphragm signs may be evident in some of the cases.[5]

CT chest will show the circumferential collection of air surrounded by a thin line of the pericardium. This collection of air does not rise above the roots of great vessels.

Ultrasonography shows horizontal reverberation artifacts obscuring the heart, appearing identical to A-lines, that occurs due to smooth air soft-tissue interface.[6] This appearance may be similar to pneumomediastinum but classically differentiated by the following features:

  • The heart remains obscured throughout the cardiac cycle
  • These A-lines involves subxiphoid window (which is characteristically spared in pneumomediastinum).


Management

Pneumopericardium, unlike pneumothorax, often does not require any specific treatment and is usually self-limiting. For small pneumopericardium treating the underlying cause will resolve it. Treatment of large and symptomatic pneumopericardium or in case of tension pneumopericardium will be needle aspiration or tube decompression. Oxygen therapy in high concentrations can also be helpful in the absorption of air in pneumopericardium.[5],[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chopra V, Garg N, Mrigpuri P. Spontaneous pneumopericardium an unusual complication in a patient of HIV and pulmonary tuberculosis. Lung India 2013;30:148-50.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Radswiki T, El-Feky M. Pneumopericardium. Reference article, Radiopaedia.org. [https://doi.org/10.53347/rID-12215].  Back to cited text no. 2
    
3.
Ladurner R, Qvick LM, Hohenbleicher F, Hallfeldt KK, Mutschler W, Mussack T. Pneumopericardium in blunt chest trauma after high-speed motor vehicle accidents. Am J Emerg Med 2005;23:83-6.  Back to cited text no. 3
    
4.
Mishra B, Joshi MK, Rattan A, Kumar S, Gupta A, Sagar S. Pneumopericardium. Bull Emerg Trauma 2016;4:250-1.  Back to cited text no. 4
    
5.
Westermann GW, Suwelack B. Spontaneous pneumopericardium due to exertion. South Med J 2003;96:50-2.  Back to cited text no. 5
    
6.
Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med 1939;64:913-26  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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