To the Editor:
Epipericardial fat necrosis is a rare, benign, and self-limited cause of acute chest
pain, with only 35 cases reported in the literature.(
11. Baig A, Campbell B, Russell M, Singh J, Borra S. Epicardial fat
necrosis: an uncommon etiology of chest pain. Cardiol J. 2012;19(4):424-8.
http://dx.doi.org/10.5603/CJ.2012.0076 PMid:22825906
http://dx.doi.org/10.5603/CJ.2012.0076 P...
,
22. Runge T, Greganti MA. Epipericardial fat necrosis - a rare cause of
pleuritic chest pain: case report and review of the literature. Arch Med Sci.
2011;7(2):337-41. http://dx.doi.org/10.5114/aoms.2011.22088 PMid:22291777
PMCid:PMC3258729
http://dx.doi.org/10.5114/aoms.2011.2208...
) It presents as new-onset pleuritic chest pain in otherwise healthy
patients, and, therefore, it is an important differential diagnosis for acute chest pain
in this group of individuals. The pathophysiology has been labeled as idiopathic or
related to an acute damage of this fat tissue secondary to vascular torsion, trauma, or
microvascular bleeding.
We report the case of a 23-year-old healthy female patient, a chronic oral contraceptive user, who presented to the emergency department with a two-day history of right-sided pleuritic chest pain, associated with mild dyspnea. No fever, cough, wheezing, or other respiratory symptoms were present. Physical examination in the emergency department revealed oxygen saturation on room air of 98%, temperature of 36.8ºC, HR of 110 bpm, RR of 24 breaths/min, and blood pressure of 110 × 65 mmHg. Laboratory tests were unremarkable. Electrocardiography showed normal sinus rhythm, whereas chest X-ray showed a slight right paracardiac opacity and tiny right pleural effusion (Figure 1A), and CT revealed a round encapsulated lesion with fat attenuation in the right epipericardial fat with subtle peripheral strands, which are typical abnormalities due to epipericardial fat necrosis (Figures 1B and 1C). Pulmonary embolism was ruled out by a contrast-enhanced protocol. The patient was then treated with nonsteroidal anti-inflammatory drugs, and her symptoms resolved in the next few days. Four weeks later, CT scans of the chest showed complete resolution of all findings (Figure 2).
In A, posteroanterior chest X-ray showing tiny pleural effusion and slight right paracardiac opacity. In B, CT scan of the chest revealing a round encapsulated lesion with fat attenuation and subtle strands in the right epipericardial fat (arrow). In C, coronal and sagittal views of the round encapsulated lesion in the right epipericardial fat (arrows), suggesting epipericardial fat necrosis.
CT scan of the chest performed four weeks after admission showing complete resolution of the previous findings.
Epipericardial fat necrosis is a rare entity, being first reported in 1957 by Jackson et
al.(
33. Pineda V, Cáceres J, Andreu J, Vilar J, Domingo ML. Epipericardial
fat necrosis: radiologic diagnosis and follow-up. AJR Am J Roentgenol.
2005;185(5):1234-6. http://dx.doi.org/10.2214/AJR.04.1310 PMid:16247140
http://dx.doi.org/10.2214/AJR.04.1310...
) Since then, other similar cases have been reported, and the most recent
studies have characterized this condition as benign and self-limited.
The epicardial or visceral layer of fat tissue is found in the interventricular groove
along the atria and extends to the right and left pleural surface. It can be more
prominent in obese individuals, in whom it can completely cover the epicardial
surface.(
11. Baig A, Campbell B, Russell M, Singh J, Borra S. Epicardial fat
necrosis: an uncommon etiology of chest pain. Cardiol J. 2012;19(4):424-8.
http://dx.doi.org/10.5603/CJ.2012.0076 PMid:22825906
http://dx.doi.org/10.5603/CJ.2012.0076 P...
)
The physiopathology of necrosis of epipericardial fat is still under debate, but an
acute torsion of a vascular pedicle has been proposed.(
33. Pineda V, Cáceres J, Andreu J, Vilar J, Domingo ML. Epipericardial
fat necrosis: radiologic diagnosis and follow-up. AJR Am J Roentgenol.
2005;185(5):1234-6. http://dx.doi.org/10.2214/AJR.04.1310 PMid:16247140
http://dx.doi.org/10.2214/AJR.04.1310...
) Indeed, small parts of fat tissue attached to the heart by a pedicle have
been found in some patients submitted to cardiac surgery,(
44. Jackson RC, Clagett OT, Mcdonald JR. Pericardial fat necrosis; report
of three cases. J Thorac Surg. 1957;33(6):723-9. PMid:13429689
) and an acute torsion of the vascular pedicle could lead to necrosis.
Another explanation would be a pre-existing structural abnormality of the adipose
tissue, making this fat vulnerable to trauma caused by the beats of the
heart.(
55. Lee BY, Song KS. Calcified chronic pericardial fat necrosis in
localized lipomatosis of pericardium. AJR Am J Roentgenol. 2007;188(1):W21-4.
http://dx.doi.org/10.2214/AJR.04.1989 PMid:17179322
http://dx.doi.org/10.2214/AJR.04.1989...
) In addition, it has been postulated that straining or heavy lifting could
trigger abrupt changes in the intravascular pressure associated with the Valsalva
maneuver, causing hemorrhage into the adipose tissue that is loosely attached to the
pericardium.(
11. Baig A, Campbell B, Russell M, Singh J, Borra S. Epicardial fat
necrosis: an uncommon etiology of chest pain. Cardiol J. 2012;19(4):424-8.
http://dx.doi.org/10.5603/CJ.2012.0076 PMid:22825906
http://dx.doi.org/10.5603/CJ.2012.0076 P...
)
The most common presentation of epipericardial fat necrosis is acute pleuritic chest
pain. There is no age or gender predilection. The pain can be associated with dizziness,
syncope, dyspnea, tachycardia, or diaphoresis. Physical examination is usually
unremarkable. In general, the pain lasts only a few days, but it can persist for weeks
and recur in intermittent episodes.(
66. Lacasse MC, Prenovault J, Lavoie A, Chartrand-Lefebvre C. Pericardial
fat necrosis presenting as acute pleuritic chest pain. J Emerg Med.
2013;44(2):e269-71. http://dx.doi.org/10.1016/j.jemermed.2012.05.032 PMid:22877971
http://dx.doi.org/10.1016/j.jemermed.201...
)
Cardiac enzymes and other laboratory tests typically show no abnormalities.
Electrocardiography is characteristically normal, but it occasionally shows findings
suggestive of resolving pericarditis.(
11. Baig A, Campbell B, Russell M, Singh J, Borra S. Epicardial fat
necrosis: an uncommon etiology of chest pain. Cardiol J. 2012;19(4):424-8.
http://dx.doi.org/10.5603/CJ.2012.0076 PMid:22825906
http://dx.doi.org/10.5603/CJ.2012.0076 P...
)
During the first days, chest X-rays can be normal or reveal small pleural effusion.
Thereafter, an ill-defined round mass appears near the cardiophrenic angle on the side
of the chest pain. These findings are nonspecific and formerly led patients to undergo
surgery due to the lack of cross-sectional imaging or the need to rule out malignancies,
such as lung cancer and liposarcoma.(
77. Inoue S, Fujino S, Tezuka N, Sawai S, Kontani K, Hanaoka J, et al.
Encapsulated pericardial fat necrosis treated by video-assisted thoracic surgery:
report of a case. Surg Today. 2000;30(8):739-43.
http://dx.doi.org/10.1007/s005950070088 PMid:10955740
http://dx.doi.org/10.1007/s005950070088...
) The pathologic findings have been described as necrotic fat cells
surrounded by macrophages, neutrophils, or fibrous tissue, resembling the features of
epiploic appendagitis.
Since 2005, when the first case of successful conservative management of epipericardial
fat necrosis was described,(
33. Pineda V, Cáceres J, Andreu J, Vilar J, Domingo ML. Epipericardial
fat necrosis: radiologic diagnosis and follow-up. AJR Am J Roentgenol.
2005;185(5):1234-6. http://dx.doi.org/10.2214/AJR.04.1310 PMid:16247140
http://dx.doi.org/10.2214/AJR.04.1310...
) CT has played an important role in the diagnosis and follow-up. The typical
finding is a round encapsulated fat-containing lesion with strands in the epipericardial
fat, which can be mild or marked. Pericardial thickening and ipsilateral pleural
effusion can also be present. Once this finding is present in a typical clinical context
and other causes of acute chest pain are ruled out, physicians should consider
epipericardial fat necrosis as the cause of pain.(
88. Mazzamuto G, Ghaye B. Epipericardial fat necrosis. JBR-BTR.
2012;95(3):154-5. PMid:22880517
)
Our patient was a young user of oral contraceptives who presented with severe right-sided pleuritic chest pain, which implicates pulmonary embolism as the main diagnosis to be ruled out. Pulmonary embolism was excluded, and epipericardial fat necrosis was visualized by CT scans, which led to the correct diagnosis and allowed the institution of conservative management with excellent results. It is imperative that clinicians and radiologists be aware of this condition in order to manage it properly in emergency departments.
References
-
1Baig A, Campbell B, Russell M, Singh J, Borra S. Epicardial fat necrosis: an uncommon etiology of chest pain. Cardiol J. 2012;19(4):424-8. http://dx.doi.org/10.5603/CJ.2012.0076 PMid:22825906
» http://dx.doi.org/10.5603/CJ.2012.0076 PMid:22825906 -
2Runge T, Greganti MA. Epipericardial fat necrosis - a rare cause of pleuritic chest pain: case report and review of the literature. Arch Med Sci. 2011;7(2):337-41. http://dx.doi.org/10.5114/aoms.2011.22088 PMid:22291777 PMCid:PMC3258729
» http://dx.doi.org/10.5114/aoms.2011.22088 -
3Pineda V, Cáceres J, Andreu J, Vilar J, Domingo ML. Epipericardial fat necrosis: radiologic diagnosis and follow-up. AJR Am J Roentgenol. 2005;185(5):1234-6. http://dx.doi.org/10.2214/AJR.04.1310 PMid:16247140
» http://dx.doi.org/10.2214/AJR.04.1310 -
4Jackson RC, Clagett OT, Mcdonald JR. Pericardial fat necrosis; report of three cases. J Thorac Surg. 1957;33(6):723-9. PMid:13429689
-
5Lee BY, Song KS. Calcified chronic pericardial fat necrosis in localized lipomatosis of pericardium. AJR Am J Roentgenol. 2007;188(1):W21-4. http://dx.doi.org/10.2214/AJR.04.1989 PMid:17179322
» http://dx.doi.org/10.2214/AJR.04.1989 -
6Lacasse MC, Prenovault J, Lavoie A, Chartrand-Lefebvre C. Pericardial fat necrosis presenting as acute pleuritic chest pain. J Emerg Med. 2013;44(2):e269-71. http://dx.doi.org/10.1016/j.jemermed.2012.05.032 PMid:22877971
» http://dx.doi.org/10.1016/j.jemermed.2012.05.032 -
7Inoue S, Fujino S, Tezuka N, Sawai S, Kontani K, Hanaoka J, et al. Encapsulated pericardial fat necrosis treated by video-assisted thoracic surgery: report of a case. Surg Today. 2000;30(8):739-43. http://dx.doi.org/10.1007/s005950070088 PMid:10955740
» http://dx.doi.org/10.1007/s005950070088 -
8Mazzamuto G, Ghaye B. Epipericardial fat necrosis. JBR-BTR. 2012;95(3):154-5. PMid:22880517
Publication Dates
-
Publication in this collection
Sep-Oct 2013
History
-
Received
17 Dec 2012 -
Accepted
14 Jan 2013