A Fatal Case of Pneumopericardium

Abstract

The first report of congenital deficiency of the pericardium was published by Realdus Columbus in 1559. Other published works in this field are by Moore in 1925 and Rusby and Sellars in 1945. In most instances the defect has been discovered by chance at necropsy, but more recently it has been reported as an operative finding. In the following case the diagnosis was made solely on clinical and radiological evidence. Case Report C. A., a 36-year-old barber, was admitted to the hospital on Nov. 19, 195.5, with pyrexia of three months duration and a mild intermittent cough productive of approximately 2 ounces of mucoid sputum, occasionally tinged with blood. The past history and family history were noncontributory. The patient was 5 feet 4 inches tall, and emaciated, weighing only 80 lb. Positive findings were limited to pallor of the skin and mucous membranes, decreased resonance over the left upper half of the chest on percussion, and fine post-tussive râles with bronchial breathing over the left infraclavicular area. Blood pressure was 140 mm. Hg systolic and 76 mm. Hg diastolic. The sputum was highly positive for acid-fast bacilli. The red cell count was 4,150,000; hemoglobin, 12.8 gm.; erythrocyte sedimentation rate 46 mm. at the end of the first hour (Westergren); white cell count 11,450 per cu. mm., with 64 per cent polyrnorphonuclcars, 27 per cent lymphocytes, 5 per cent monocytes, and 2 per cent eosinophils. Urine was normal and the serologic test for syphilis was negative. A postero-anterior roentgenogram of the chest revealed patchy confluent densities in the left upper lobe, with a small cavity projected through the second rib anteriorly. The right apex also showed a zone of infiltration. Treatment was begun with bed rest, streptomycin (1.0 gm. every third day), isoniazid (8 mg. per kg., per day), and general supportive measures. On the seventh day following admission, the patient experienced a sudden pain in the left side of the chest, with pallor, dyspnea, and profuse sweating. Heart sounds were muffled. On percussion there was increased resonance over the precardial area. A postero-anterior roentgenogram of the chest obtained at this time (Fig. 1) showed a striking change from the small cavity originally seen in the left subelavicular area to an interlobar hydropneumothorax. The cardiac silhouette was distinctly circumscribed by an air-filled sac. A tentative diagnosis of pneumopericardium with mediastino-interlobar hydropneumothorax was made. A repeat roentgenogram the following morning (Fig. 2) revealed fluid in the pleural cavity up to the fifth rib posteriorly, with pneumopericardium still present. Thoracentesis two days after the acute onset of the syndrome yielded 400 c.c. of fluid, which was found positive for Mycobacterium tuberculosis.