A.L. McLeod, N.G. Dewhurst
Tayside Hospitals University Trust, Dundee
Pericardial cysts are rare mediastinal cysts, which are commonly asymptomatic. We report the case of a middle-aged lady, with a previous short history of chest pain, who was found to have a focal pericardial density, felt to have been a consequence of haemorrhage into such a cyst.
Key words: Pericardial cyst, chest pain
Pericardial cysts are uncommon and often remain asymptomatic, their discovery incidental. This case report illustrates a complication in a lady with a focal pericardial density, whom reported a previous short history of chest pain.
A 48-year-old nurse was referred with a pericardial calcific density. She had no risk factors for coronary artery disease and was on no medications. She had previously kept well, though in 1998 she had an episode of severe sharp central chest pain with no radiation following which she did not attend hospital.
Three years later and following a six-week history of episodic epigastric pain an abdominal ultrasound identified a 4.7 x 3.8cm homogenous lesion in the liver on ultrasound. Routine haematology, biochemistry and an upper GI endoscopy were normal. A PA chest x-ray had revealed a normal cardiac and mediastinal contour with clear lung fields and no evidence of cardiomegaly. However, a penetrated lateral view of the sternum revealed a faintly visualised area of calcification, measuring approximately 2cm, overlying the inferior and anterior part of the heart. (Fig 1)
Computerised tomography (Fig 2) confirmed the abdominal ultrasound findings, and with enhancement suggested an area of focal nodular hyperplasia. The area of calcific density seen on the chest x-ray appeared to lie within the pericardium, antero-inferiorly to the right ventricle, and showed marked attentuation (300-400 Houndsfield Inits) in keeping with calcification. There was no cystic component. Echocardiography failed to visualise the lesion.
Pericardial cysts are rare mediastinal cysts with an incidence of 1 in 100,000. The focal calcific density was felt to have been the result of prefious haemorrhage into such a cyst. Pericardial cysts are outpouchings of the parietal pericardium, and are most commonly found in the right costophrenic angle, however up to a third are found in other locations, notably the right border of the heard and superior mediastinum.
Though most patients are asymptomatic, chest pain (22%) and dyspnoea (10%) are the most reported symptoms, resulting directly from either torsion or a rapid increase in cyst volume due to haemorrhage,1,2 the latter the most likely contributing to this patient's symptoms in 1998. Larger cysts have been associated with right ventricular outflow tract obstruction and cardiogenic shock.3,4,5 Computer axial tomography is of value in both anatomical mapping and differentiation of cystic masses from, for example, fat pads and lipomas, though only cyst puncture gives definitive cytology. Pericardial cyst aspiration is of value in symptomatic patients, however, management of asymptomatic patients is conservative as long term follow-up studies suggest that they do not develop symptoms.6 Our patient has remained asymptomatic.
R E F E R E N C E S
1 Feigin DS, Fenoglio JJ, McAllister HA et al. Pericardial cysts. A radiologic-pathologic correlation and review. Radiology 1977; 125(1): 15-20.
2 Klatte E et al. Diagnosis and treatment of pericardial cysts. Radiology 1972; 104(9): 541-44.
3 Okubo K, Chino M, Fuse J et al. Life-saving needle aspiration of a cardiac-compressing cyst. Am J of Cardiol 2000; 85: 521.
4 Borges AC, Gellert K, Dietel M et al. Acute right sided heart failure due to haemorrhage into a pericardial cyst. Ann Thorac Surg 1977; 63: 845-47.
5 Borges AC, Arthur et al. Ann Thoracic Surg 1997; 63: 1147-48.
6 Mocada et al. J Comput Assist Tomogr 1985; 9: 56.