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CASE REPORT

Continuous left hemidiaphragm sign revisited: a case of spontaneous pneumopericardium and literature review
L Brander, D Ramsay, D Dreier, M Peter, R Graeni
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Heart 2002;88:e5 (http://www.heartjnl.com/cgi/content/full/88/e5)

In pneumopericardium, a rare but potentially life threatening differential diagnosis of chest pain with a broad variety of causes, rapid diagnosis and adequate treatment are crucial. In upright posteroanterior chest radiography, the apical limit of a radiolucent rim, outlining both the left ventricle and the right atrium, lies at the level of the pulmonary artery and ascending aorta, reflecting the anatomical limits of the pericardium. The band of gas surrounding the heart may outline the normally invisible parts of the diaphragm, producing the continuous left hemidiaphragm sign in an upright lateral chest radiograph. If haemodynamic conditions are stable, the underlying condition should be treated and the patient should be monitored closely. Acute haemodynamic deterioration should prompt rapid further investigation and cardiac tamponade must be actively ruled out. Spontaneous pneumopericardium in a 20 year old man is presented, and its pathophysiology described.

neumopericardium is a rare condition, less common than either isolated pneumothorax or pneumomediastinum. Nevertheless, clinicians should be familiar with this differential diagnosis of chest pain and its clinical and radiographic manifestations, since prompt recognition and treatment of potential complicationsmost importantly, pericardial tamponademay be life saving.

Figure 1 Posteroanterior chest radiograph. Continuous radiolucent stripes follow the right and left cardiac borders and are outlined by a fine line (arrows) representing the pericardial sac. The stripes are limited at the level of the pulmonary artery and ascending aorta by the pericardial reflection.

CASE REPORT

A previously healthy 20 year old man was admitted to the hospital two hours after the acute onset of left sided chest pain radiating to his left arm and neck, worsening in the left lateral recumbent position and exacerbated by deep inspiration. Symptoms had developed one hour after he had been chopping wood. He reported rhinitis of two weeks duration but did not have other respiratory tract symptoms or fever. He had a smoking history of two pack years. On physical examination the patient was in moderate distress, his temperature was 36.6C, pulse 74 beats/min, and blood pressure 130/65 mm Hg without pulsus paradoxus. Cardiac examination was notable for a left parasternal rub, but there was no clinically evident right heart failure or subcutaneous emphysema. Routine laboratory tests were within normal limits, including white cell count, C reactive protein, creatine phosphokinase, and troponin I. The ECG showed a sinus rhythm with normal repolarisation. Plain radiographs of the chest showed a pneumopericardium (g 1) with the continuous left hemidiaphragm sign (g 2) and a discrete pneumomediastinum. Transthoracic echocardiography was unremarkable. Three days after admission with resolution of the radiographic ndings, the patients symptoms subsided spontaneously. He remained asymptomatic 12 months after discharge from the hospital.

Pneumopericardium is a rare but important differential diagnosis of chest pain. Symptoms such as radiation of pain towards the shoulders, the back, or the epigastrium, as well as dyspnoea and palpitations, are not always present and depend on the extent of pneumopericardium and the underlying disease. Clinical signs such as distant heart sounds, shifting precordial tympany, and a succussion splash with metallic tinkling (referred to as the mill wheel murmur, or bruit de moulin in hydropneumopericardium and rst described by Bricketeau in 1844)1 2 and ECG ndings such as low voltage, ST segment changes, and T wave inversion are non-specic and unreliable. Hammans crunch of pneumomediastinum and palpable crepitation of subcutaneous emphysema should heighten suspicion.3 Sufcient accumulation of pericardial gas may impair right ventricular lling, resulting in pericardial tamponade with increase and equalisation of intracardiac pressures, pulsus paradoxus, arterial hypotension, and cardiogenic shock.4 5 The diagnosis of pneumopericardium can be conrmed by conventional chest radiographs,6 computed tomography, or echocardiography.7 8 Radiographic ndings of pneumopericardium and pneumomediastinum can be similar in the lower mediastinum. In posteroanterior chest radiographs, a continuous thin radiolucent rim of air follows the cardiac silhouette and is outlined by

DISCUSSION

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Brander, Ramsay, Dreier, et al

Table 1
Aetiology

Causes of pneumopericardium
References 3, 24, 25 26, 27, 28 29, 30 31 32, 33, 34 35 36 37 24 38 39 40 41 42

Figure 2 Upright lateral chest radiograph. The normally invisible ventral part of the left hemidiaphragm (arrows) is outlined by a radiolucent rim, producing the continuous left hemidiaphragm sign. The air bubble in the stomach identifies the left hemidiaphragm.

a ne line representing the pericardial sac (g 1). At the base of the heart, the gas may outline the superior surface of the normally obscured parts of the diaphragm, which can be seen on the lateral radiograph as the continuous left hemidiaphragm sign6 9 (g 2) and on a frontal radiograph as the continuous diaphragm sign.6 Some radiographic signs may help differentiate pneumopericardium from pneumomediastinum, although for pathophysiological reasons, both can coincide. In pneumopericardium a single band of gas, which is curved and sharply marginated by the pericardial sac, outlines both the left ventricle and the right atrium, and its apical limit lies at the level of the pulmonary artery and ascending aorta, reecting the anatomical limits of the pericardium (g 1). Air outlining the aortic arch, the superior vena cava above the azygos vein, or the distal left pulmonary artery must be outside the pericardium.6 If present, any pericardial thickening or effusion (hydropneumopericardium) helps distinguish the two conditions.6 In pneumomediastinum, gas does not usually surround the heart completely, is not conned to the region of the heart, and can be seen as multiple thin streaks of gas extending to the superior mediastinum and neck. The mediastinal pleura follows the contours of the pericardium except in the perihilar region and behind the sternum. In lateral decubitus radiographs, gas in the pericardial (and pleural) space shifts to the non-dependent side, whereas intramediastinal air is trapped within the soft tissue and does not cross to the contralateral side.6 In tension pneumopericardium the cardiothoracic ratio may decrease and the heart may appear extremely slender (small heart sign).10 It has been suggested that shearing forces rupturing the marginal alveolar bases, dissecting the peribronchial and perivascular sheaths with resulting escape of air towards either the pleural space, the hilum, or both, are involved in the pathogenesis of pneumothorax and pneumomediastinum in barotrauma, as well as in blunt chest trauma.3 11 Air spreading peripherally along the pulmonary arteries and veins dissecting through the pericardium along these vessels can result in pneumopericardium.12 Histological preparations have identied a site of potential weakness where the parietal

Trauma Penetrating and blunt chest trauma Invasive procedures Laparoscopy Endoscopic colon perforation Sternal bone marrow aspiration Thoracotomy Tracheostomy Endotracheal intubation Endotracheal laser surgery Thoracocentesis Cauterisation of oesophageal webs Endoscopic papillotomy Dental extraction Pneumoencephalography Inert gas in the pleural space after pneumonectomy Fistula to the pericardium Cancer of the oesophagus, stomach, and bronchus Oesophageal or gastric ulcer Pressure gastric ulcer from phytobezoar Achalasia Pneumonia with abscess Pulmonary aspergillosis Tuberculosis (lung and pleura) Subphrenic colonic abscess Amoebic liver abscess Foreign body aspiration Postoperative complications Barotrauma High end expiratory pressure In adults In neonates and infants Acute asthma Coughing Heimlich manoeuvre Valsalva manoeuvre in physical effort Labour and delivery Inhalation of illicit drugs with positive pressure devices High pressure air injection Rectal barotraumas Pericardial infection Histoplasma capsulatum Purulent pericarditis Gas forming organisms

43, 44, 45, 46 23, 47, 48, 49, 50 51 52 9, 53 54, 55 24 56 57, 58 59 50

18, 20 13, 16, 17, 19, 21 12 61, 63 64 This report 60, 65, 66, 67 68, 69, 70 71 72 73 74 25

pericardium is reected on the visceral pericardium near the ostia of the pulmonary veins.13 The pleural or tracheobronchial and pericardial spaces may be directly connected as a consequence of pericardial tear or rupture in chest trauma.3 14 Congenital pleuropericardial defects have been described.15 Positive pressure ventilation with large tidal volumes or high end expiratory pressure may cause or worsen the condition, particularly in neonates or infants .13 1621 Since pneumopericardium in case of a pre-existing stula to the pericardium may be worsened by insufation of pressurised air during gastrointestinal endoscopy, this examination should be performed in a well controlled setting with access to emergency pericardiocentesis or surgery.22 Visualisation of the stula with contrast media may be helpful.23 As table 1 summarises, pneumopericardium has been reported to result from blunt and penetrating chest trauma,3 24 25 as a complication of invasive procedures,24 2642 from abnormal communications such as stulas from the pericardium to the adjacent structures containing air from different causes,9 23 24 4359 from barotrauma,12 13 1621 6072 and from pericardial infections.25 73 74 In our patient we hypothesise that barotrauma (Valsalva manoeuvre) during physical effort and probably impaired

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23 Cozart J, Sundaresan S, Chokshi HR, et al. Gastropericardial fistula with pneumopericardium: an unusual complication of benign peptic ulceration. Gastrointest Endosc 1999;49:38790. 24 Shackelford RT. Hydropneumopericardium: report of case with summary of literature. JAMA 1931;96:18791. 25 Cummings RG, Wesly RL, Adams DH, et al. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg 1984;37:5118. 26 Beaver J, Safran D. Pneumopericardium mimicking acute myocardial ischemia after laparoscopic cholecystectomy. South Med J 1999;92:10024. 27 Knos GB, Sung YF, Toledo A. Pneumopericardium associated with laparoscopy. J Clin Anesth 1991;3:569. 28 Nicholson RD, Berman ND. Pneumopericardium following laparascopy. Chest 1979;76:6057. 29 Bakker J, van Kersen F, Bellaar Spruyt J. Pneumopericardium and pneumomediastinum after polypectomy. Endoscopy 1991;23:467. 30 Fitzgerald SD, Denk A, Flynn M, et al. Pneumopericardium and subcutaneous emphysema of the neck: an unusual manifestation of colonoscopic perforation. Surg Endosc 1992;6:1413. 31 Ackerman JL, Alden JW. Pneumopericardium following sternal bone marrow aspiration. Radiology 1958;70:4089. 32 Shawl FA, Chun PKC. Pneumopericardial tamponade post coronary artery bypass sternal dehiscence. Am Heart J 1982;104:1603. 33 Brandenhoff P, Hoier-Madsen K, Struve-Christensen E. Pneumopericardium after pneumonectomy and lobectomy. Thorax 1986;41:557. 34 Hymes WA, Itani KM, Wall WJ Jr, et al. Delayed tension pneumopericardium after thoracotomy for penetrating chest trauma. Ann Thorac Surg 1994;57:165860. 35 Posthumus DL, Peirce TH. Fatal tension pneumopericardium complicating tracheostomy. Chest 1978;73:1079. 36 ONeill D, Symon DN. Pneumopericardium and pneumomediastinum complicating endotracheal intubation. Postgrad Med J 1979;55:2735. 37 Vourch G, Le Gall R, Colchen A. Pneumopericardium: an unusual complication of endotracheal laser surgery. Br J Anaesth 1985;57:4512. 38 Stephenson SE, Maness G, Scott HW. Esophagopericardial fistula of benign origin. J Thorac Surg 1958;36:20813. 39 Schoenemann J. Pneumoperikard sowie retroperitoneales und Skrotalemphysem nach endoskopischer Papillotomie. Z Gastroenterol 2000;38:457. 40 Sandler CM, Libshitz HI, Marks G. Pneumoperitoneum, pneumomediastinum and pneumopericardium following dental extraction. Radiology 1975;115:53940. 41 Tsai FY, Lee KF. Pneumopericardium and pneumomediastinum: rate complications of pneumoencephalography. Radiology 1974;112:957. 42 Shirakusa T. Fatal pneumopericardium caused by SF6 gas infusion into the pleural space after pneumonectomy and pericardial resection. Chest 1989;95:13501. 43 Vennos AD, Templeton PA. Pneumopericardium secondary to esophageal carcinoma. Radiology 1992;182:1312. 44 Katzir D, Klinovsky E, Kent V, et al. Spontaneous pneumopericardium: case report and review of the literature. Cardiology 1989;76:3058. 45 Cramm RE, Robinson FW. Pneumopericardium associated with gastric cancer: report of a case and literature review. Gastroenterology 1971;60:3115. 46 Harris RD, Kostiner AI. Pneumopericardium associated with bronchogenic carcinoma. Chest 1975;67:1156. 47 Stridbeck H, Samuelsson L. Pneumopyopericardium. Acta Radiol Diagn 1983;24:3058. 48 Letoquart JP, Fasquel JL, LHuillier JP, et al. Gastropericardial fistula: review of the literature apropos of an original case. J Chir (Paris) 1990;127:612. 49 Miller WL, Osborn MJ, Sinak LJ, et al. Pyopneumopericardium attributed to an esophagopericardial fistula: report of a survivor and review of the literature. Mayo Clin Proc 1991;66:10415. 50 Schneider F, Schenk M, Tempe JD, et al. Spontaneous gastropericardial fistula. Ann Emerg Med 1995;26:394. 51 Bianchi C, Di Bonito L, Fonda F, et al. Pericardial perforation of a gastric ulcer secondary to phytobezoar. Panminerva Med 1977;19:3536. 52 Breatnach E, Han SY. Pneumopericardium occurring as a complication of achalasia. Chest 1986;90:2923. 53 Smith LG, Naqvi T. Images in clinical medicine: tension pneumopericardium. N Engl J Med 1995;332:1481. 54 Van Ede AE, Meis JF, Koot RA, et al. Pneumopericardium complicating invasive pulmonary aspergillosis: case report and review. Infection 1994;22:1025. 55 Muller NL, Miller RR, Ostrow DN, et al. Tension pneumopericardium: an unusual manifestation of invasive pulmonary aspergillosis. Am J Roentgenol 1987;148:67880. 56 Pfaff C, Hunter TB, Silverstein ME, et al. Pneumopericardium secondary to a fistula: communication between pericardium and subphrenic-colonic abscess. JAMA 1976;235:25223. 57 Freeman AL, Bhoola KD. Pneumopericardium complicating amoebic liver abscess. S Afr Med J 1976;50:5513. 58 Satija VK, Eggleston FC, Pawar B, et al. Pneumo-pericardium complicating amoebic liver abscess. J Assoc Physicians India 1987;35:5946. 59 Tjhen KY, Schmaltz AA, Ibrahim Z, et al. Pneumopericardium as a complication of foreign body aspiration. Pediatr Radiol 1978;7:1213. 60 Bjorklund L, Lindroth M, Malmgren N, et al. Spontaneous pneumopericardium in an otherwise healthy full-term newborn. Acta Paediatr Scand 1990;79:2346.

alveolar integrity resulting from upper airway infection ultimately caused a pneumopericardium, which was accompanied by slight pneumomediastinum. Acute haemodynamic deterioration in a patient with pneumopericardium should prompt further investigation and cardiac tamponade should be actively ruled out. In tension pneumopericardium, rapid uid resuscitation and emergent pericardiocentesis with echocardiographic guidance and haemodynamic monitoring, followed by pericardial fenestration and pericardial drainage, should be performed.3 25 With stable haemodynamic conditions and absent tamponade, the underlying condition should be treated and the patient should be monitored closely.
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Authors affiliations

L Brander, Department of Intensive Care Medicine, University Hospital, Bern, Switzerland D Ramsay, Division of Circulatory Physiology, Columbia Presbyterian Medical Center, New York, New York, USA D Dreier, M Peter, R Graeni, Departments of Internal Medicine and Radiology, Kantonales Spital Sursee-Wolhusen, Wolhusen, Switzerland Correspondence to: Dr L Brander, Department of Intensive Care Medicine, University Hospital, 3010 Bern, Switzerland; lukas.brander@insel.ch Accepted 12 June 2002

REFERENCES

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