Advertisement

Journal of General Internal Medicine

, Volume 31, Issue 1, pp 138–138 | Cite as

An Often-Overlooked Etiology of Pleuritic Chest Pain

  • Jacob E. BerchuckEmail author
  • Shalini Patel
Clinical Practice: Clinical Images

KEY WORDS

Clinical image Diagnosis Cardiovascular disease Pulmonary disease 
An 80-year-old man with history of coronary artery disease (CAD) and deep vein thrombosis (DVT) was admitted for left-sided pleuritic chest pain. Physical exam, ECG, CBC, electrolytes, and troponin were unrevealing. Chest CT with contrast demonstrated a swirling soft tissue density in the anterior mediastinum, with prominent epipericardial fat stranding extending inward to the pericardial surface with inflammatory changes of the left posterior pericardium itself, consistent with epipericardial fat necrosis (EPFN). Ibuprofen was started, and at 3-month follow-up, chest pain had resolved and CT showed near complete resolution of the initial radiographic findings (Fig. 1).
Fig. 1

The patient’s chest CT showing characteristic radiographic findings of epipericardial fat necrosis

EPFN is an often-overlooked etiology of pleuritic chest pain in patients with a negative cardiopulmonary workup.1 Onset is usually acute, but can persist up to a year. ECG and lab tests are usually normal. CXR often shows a paracardiac opacity, occasionally with an associated pleural effusion. CT shows an ovoid density in the juxtapericardial fat, with prominent stranding extending to the pericardial surface with inflammatory changes of the pericardium.2 The triad of pleuritic chest pain, classic CT findings, and negative cardiopulmonary work-up is highly suggestive of EPFN.3 Because of its self-limiting nature, the treatment is conservative management with NSAIDs.4 Follow-up imaging is recommended to confirm resolution and exclude neoplastic diseases such as liposarcoma.

Notes

Conflict of interest

The authors report no conflicts of interest related to the work described in this manuscript.

References

  1. 1.
    Giassi Kde S, Costa AN, Bachion GH, et al. Epipericardial fat necrosis: an underdiagnosed condition. Br J Radiol. 2014;87:20140118.PubMedCrossRefGoogle Scholar
  2. 2.
    Bhatt MY, Martínez-Jiménez S, Rosado-de-Christenson M, Watson K, Walker CM, Kunin JR. Imaging manifestations of mediastinal fat necrosis. Case Rep Radiol. 2013;2013:323579.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Pineda V, Cáceres J, Andreu J, Vilar J, Domingo ML. Epipericardial fat necrosis: radiologic diagnosis and follow-up. Am J Roentgenol. 2005;185:1234–6.CrossRefGoogle Scholar
  4. 4.
    Jouan F, Sacre K, Debray MP, Crestani B, Chauveheid MP, Papo T. A 70-year-old woman with acute chest pain and a paracardiac mass. Chest. 2013;143(3):866–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2015

Authors and Affiliations

  1. 1.Department of MedicineUniversity of California San FranciscoSan FranciscoUSA
  2. 2.Department of MedicineSan Francisco Veterans Affairs Medical CenterSan FranciscoUSA

Personalised recommendations