SAEM Clinical Images Series: A Rare Cause of Dyspnea
A 73-year-old female with past medical history significant for Roux-en-Y gastric bypass 14 years prior complicated by gastro-jejunal ulcers, rheumatoid arthritis on daily prednisone for six months, coronary artery disease, history of remote pulmonary embolism no longer on anticoagulation, GERD, non-insulin dependent type 2 diabetes, morbid obesity, and chronic obstructive pulmonary disease, presented with two-week progression of dyspnea after a ground level fall. She endorsed pain to her neck, back, and stomach. She denied any chest pain, cough, hemoptysis, fevers, chills, leg pain, leg swelling, wheezing, recent surgeries or hospitalizations, recent travel, or history of tobacco use.
Vitals: Temp 98.4°F; HR 81; BP 61/46; RR 19; O2 sat 96% on 6L nasal cannula
General: Not in acute respiratory distress. Appears ill.
Neurologic: A&OX4. Face is symmetrical. Following commands. Moves all four limbs spontaneously.
Cardiovascular: Normal rate and rhythm without murmurs, gallops, or rubs. Heart sounds are muffled. Unable to assess for JVD due to body habitus.
Pulmonary: Lungs clear to auscultation bilaterally. No wheezing, rhonchi, rales. No accessory muscle use. Speaking in full sentences.
Abdominal: Diffusely tender to deep palpation. No rebounding, guarding, or tenderness.
Extremities: DPs 2+ and radials 2+. No asymmetric leg swelling. Legs non-tender.
CBC: WBC 12.5 k/µL, hemoglobin 10.3 g/dL
Lactate: 5.0 mmol/L
ABG: pH 7.34, PaCO2 28.3 mmHg, PaO2 78.5 mmHg, O2 sat 94.5%, bicarb 14.8 mmol/L
Blood glucose: 125 mg/dL
Troponin: 132, 133 ng/L.
EKG: Normal sinus rhythm with low voltage and ST-segment elevations in lead II, V3-V6
The diagnosis is pyopneumopericarditis from a pericardial-jejunal fistula. The differential diagnosis for pneumopericarditis includes a history of blunt or penetrating trauma, thoracic surgery or pericardial fluid drainage, positive pressure ventilation, and infectious pericarditis. In this case, the cause was a fistula likely as a side effect of chronic steroid use, which increases the risk of peptic ulcer disease.
Definitive management requires operative intervention with thoracic surgery. Pneumopericarditis carries a high mortality risk and a high risk for tamponade or cardiogenic shock from myopericarditis, as well as septic shock if infection is also present. Therefore, disposition for these patients usually requires surgical intensive care for close hemodynamic and respiratory monitoring and support. It is prudent to start broad-spectrum antibiotics and obtain blood cultures, as well as intraoperative pericardial fluid cultures to narrow antibiotic selection. CT esophagram and/or endoscopy is often indicated to rule out a pericardial-enteric fistula if there are no other immediate causes unveiled on history and examination. The patient should also receive aspirin and colchicine if concomitant myopericarditis is present.
Take-Home Points
Pneumopericarditis requires early, aggressive operative intervention and intensive care management.
Use steroids judiciously in patients with known gastritis or peptic ulcer disease.
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