INTRODUCTION: Pericardial cysts represent 6-7% of all mediastinal masses, with an estimated incidence of 1:100,000. They are benign, almost always congenital,may be unilocular or multilocular, with diameter from 1-5 cm. Though occasionally associated with symptoms related to compression of surrounding structures, pericardial cysts are usually asymptomatic and almost always diagnosed incidentally. In this case history report, we describe a patient with a pericardial cyst for whom presentation and course of illness were unusual.
CASE PRESENTATION: A 30 year old South African male with no medical history was admitted twice to our hospital for syncope and chest pain. The episodes lasted 15-30 seconds and were preceded by dizziness and diaphoresis. For one week prior, he experienced intermittent, pleuritic chest pain that was positional with an associated burning sensation that radiated to his clavicles. This presentation represented the third such episode of chest pain in the past year. There was no recent weight loss, cough, sputum production, sick contacts, exposure to tuberculosis, joint pain, or rash. The patient had a normal chest x-ray 7 years prior. On physical examination, vital signs were normal; the only abnormalities were decreased breath sounds with crackles and egophony bilaterally at the lung bases. His electrocardiogram did not reveal any abnormalities. Chest x-ray showed a large opacity obscuring the right heart border. A chest computer tomography (CT)revealed bilateral small pleural effusions, a pericardial effusion, and a 5.6 x 5.6 cm complex fluid collection at the right pericardial border; it was unclear whether the collection communicated with the pericardial cavity or was adjacent to the pericardium. Except for a small pericardial effusion, an echocardiogram was normal without signs of tamponade. No cyst was seen. Extensive work-up for infectious and inflammatory causes, including blood cultures, viral antibodies, sputum AFB’s, PPD testing, and collagen vascular disease markers, were negative. The patient’s symptoms resolved quickly while in the hospital. He preferred a conservative approach and was discharged home with outpatient follow-up. Follow-up chest x-ray one month later showed near-complete resolution of the right heart border opacity and the patient was symptom-free. He returned two months later to the hospital with syncope very similar to the previous episode, again preceded by a few days of intermittent pleuritic chest pain. The chest CT showed reappearance of a sizable pericardial effusion and enhancement of the parietal pericardium suggesting pericarditis, as well as reappearance of the pericardial fluid collection. On right video-assisted thoracoscopic exploration, a large ruptured pericardial cyst with minimal fluid was noted. The remainder of the pleura and pericardium appeared normal. The pericardial cyst was excised and the patient was discharged uneventfully. The patient remains symptoms free 6 months later.
DISCUSSION: While most pericardial cysts are congenital there are case reports of acquired cysts. To our knowledge this is the first case report of a pericardial cyst that presented with intermittent symptoms (in this case syncope, acute pericarditis, pleurisy, and pneumonitis) and radiographically resolved only then to recur. The presentation suggests vagal syncope, likely related to the pain of pericardial cyst rupture and not to pericardial tamponade. While usually asymptomatic and discovered incidentally on chest x-ray, pericardial cysts can present with chest discomfort, dyspnea, cough,palpitations due to compression of the heart. Rarely, pericardial cysts calcify or rupture. CT and MRI have high sensitivity for identifying the water density of the cyst; this diagnosis is therefore usually made non-operatively. No treatment is required for a congenital pericardial cyst unless symptomatic, in which case cysts may be treated by percutaneous aspiration and ethanol injection. Surgical excision, preferably by minimally invasive techniques can also be performed with decreased rates of recurrence compared to percutaneous techniques. In this case rupture of the cyst was associated each time with inflammatory non-infectious pleuropericarditis and pneumonitis presumably caused by the leakage of cyst fluid.
CONCLUSIONS: Pericardial cysts are rare, and usually clinically silent. Occasionally they cause complications, some of which are severe and even life-threatening. Our case demonstrated recurrent cyst rupture which presented as syncope and was complicated by pleuropericarditis and pneumonitis.
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DISCLOSURE: The following authors have nothing to disclose: Tiberio Frisoli, Horiana Grosu, Subrato Paul, Edward Eden
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