Discussion
Pneumopericardium is rare in adults and is typically described as a
result of chest trauma or iatrogenic complication of an invasive
procedure (1)(2). It has also been described spontaneously (1) and as a
rare complication of pericardiocentesis (3)(4). A recent case series
brought light to cancer-related pneumopericadium, and identified 11
reported cases in the literature, 10 of which were in adult males and
occurred as a result of a fistulous communication with the esophagus or
bronchus (5). To our knowledge, this is the first reported case of
pneumopericardium as a result of a fistulous communication with the
distal trachea, in this case, manifesting after pericardiocentesis.
Fistulous pneumopericardium should be suspected whenever a patient with
gastroesophageal or tracheobronchial malignancy presents with chest pain
or shortness of breath. Diagnosis can be achieved by chest X-ray showing
the appearance of a radiolucent rim around the cardiac shadow, and
computed tomography can help demonstrate the presence of a fistulous
communication. Treatment depends on the hemodynamic stability of the
patient, the presence and location of a fistula, and the overall
prognosis and functional status of the patient. Patients with
hemodynamic compromise should be treated with pericardiocentesis, while
hemodynamically stable patients can be managed conservatively with
watchful surveillance for spontaneous absorption of air. If a fistula is
present, stenting using endoscopy or bronchoscopy can be pursued to
block the fistulous connection and prevent further accumulation of
pericardial air. In the presence of an infiltrating malignancy, goals of
care should be discussed with the patient and family.