Spontaneous pneumopericardium in a patient with lung cancer.

A 67-year-old man with a 50 pack-year smoking history was admitted to the emergency department with a chest pain, irradiating to his left shoulder. The patient also reported history of dyspnoea in the last month, with productive cough, haemoptysis, and weight loss. Thoracic radiography presented a consolidation in the upper left pulmonary lobe and signs of pneumopericardium (Figure ). For better characterization, a thoracic computed tomography (CT) was performed and revealed a left pulmonary mass with 77 × 45 mm, containing small areas of central necrosis and gas, associated with an anterior pneumopericardium due to a direct pleuro-pericardial communication (Figure ). Transthoracic echocardiography (TTE) revealed air bubbles in the pericardial space and ‘the air gap sign’, translating the disappearance of the cardiac silhouette in systole. Due to a stable haemodynamic status with no clinical or echocardiographic signs of tension pneumopericardium, the patient was closely monitored and managed conservatively under watchful observation. The remaining study showed that it was a pulmonary adenocarcinoma with brain, liver, and bone metastasis. The patient’s condition deteriorated rapidly, dying after 1 month of hospitalization under palliative therapy. The pneumopericardium is an uncommon and potentially serious condition. Described cases of pneumopericardium in patients with lung cancer are extremely rare, with very few cases in the literature. In this clinical case, the existence of the pneumopericardium was due to a direct pleuro-pericardial communication. On both thoracic radiographs and CT, the diagnosis is established by the presence of a paracardiac radiotransparent band that separates the pericardium from the heart, called ‘continuous diaphragm sign’. TTE findings can show two pathognomonic signs. The ‘air gap sign’ which causes a cyclic loss of echo signal during systole, and the ‘swirling bubbles sign’ by several very small bright echogenic spots in the pericardial sac evoking micro air bubbles.

Anteroposterior thoracic radiography demonstrating a pneumopericardium and a consolidation in the upper left pulmonary lobe.

Axial computed tomography scan a highlighting a left pulmonary mass, containing small areas of central necrosis and gas, associated to an anterior pneumopericardium due to a direct pleuro-pericardial communication.

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Conflict of interest: none declared.