Tension Pneumopericardium in Hodgkin’s Disease
A 76-year-old woman presented with a 6-month history of weight loss and progressive dyspnea. A contrast-enhanced computed tomography (CT) scan showed a retrosternal mass with displacement of the structures in the anterior mediastinum and bilateral pleural effusions. Excision biopsy of a cervical lymph node showed nodular sclerosing Hodgkin’s lymphoma. She was started on corticosteroid treatment and underwent drainage of her left-sided pleural effusion via a chest tube.
After initial improvement, she developed progressive respiratory insufficiency for which she received noninvasive positive pressure ventilation. In the next 2 hours she became hemodynamically unstable and was intubated, volume resuscitated, and commenced on noradrenalin infusion. Figure 1 and Figure 2 show an ECG done 7 days before and an ECG during this event, respectively.
The chest radiography film and the thoracic CT showed a pneumopericardium (Figures 3 and 4⇓). Emergency subxiphoid pericardiocentesis resulted in an immediate increase in blood pressure (Figure 5). After consulting the patient’s family, the thoracosurgical team refrained from further operative treatment, and the patient died of recurrent pneumopericardium.
Autopsy showed Hodgkin’s disease with extensive involvement of the mediastinum, lungs, and liver. The trachea showed infiltration with Hodgkin’s lymphoma and necrosis containing a fistula connecting the trachea and the pericardial sac (Figures 6 and 7⇓). In this patient, the combination of corticosteroid-induced necrosis of lymphomatous tissue together with positive pressure ventilation resulted in the formation of a fistula that led to air trapping in the pericardial sac.