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Weekly Chest CasesArchive of Old Cases

Case No : 757 Date 2012-04-30

  • Courtesy of Tae Yoon Kim, Dae Hee Han, Jung Im Jung, Myeong Im Jeong / Catholic University of Korea, Seoul St. Mary's Hospital.
  • Age/Sex 12 / M
  • Chief ComplaintHigh fever and chest pain 1 mo. after minimally invasive repair surgery for Pectus excavatum.
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Figure 1. 4 days after surgery.

Diagnosis With Brief Discussion

Diagnosis
Postpericardiotomy syndrome
Radiologic Findings
Fig 1) Posteroanterior chest radiograph on postoperative day 4 shows minimal bilateral effusions and normal heart size. The radiograph shows two pectus bars across the middle and lower lung zones, respectively. A chest tube is noted in the right hemithorax.
(Fig 2) Posteroanterior chest radiograph, obtained one month after the surgery, shows enlarged cardiac shadow from pericardial effusion which correlated with onset of clinical symptoms. Obliteration of the right and left lateral costophrenic angles is still present.
(Fig 3) Contrast-enhanced CT at the level of the ventricles show moderate amount of pericardial effusion, with diffuse pericardial enhancement.
(Fig 4) Posteroanterior chest radiograph, obtained one month after initiation of NSAID and steroid therapy, shows normalization of lateral costophrenic angles and cardiac size, indicating resolving of pleural and pericardial effusions.
Brief Review
Postpericardiotomy syndrome (PPS) is a relatively common (10-40%) and troublesome complication following cardiac surgery and occurring a few days to several weeks after the surgical operation that involves entry into the pericardium. It is thought to be the result of an immune response of the epicardial layer of the myocardium. The clinical symptoms of PPS with fever and chest pain predominating, and delayed in onset, reflect the pleuropericardial involvement. Postpericardiotomy syndrome usually manifests as a mild, self-limited inflammatory illness. The radiographic findings in the immediate postoperative period (the first 3 postoperative days) do not differ in those patients who later develop PPS and those who do not. Radiographic abnormalities develop almost always within 2 days either before or after the onset of the clinical manifestations. According to the study by Kaminsky et al. (38 patients), they include pleural and pericardial effusion (n=11), pleural effusion alone (n=11), pericardial effusion alone (n=4), pleural effusion and pericardial effusion and pulmonary infiltrates (n=3), and pleural effusion and pulmonary infiltrates (n=1). In none of their patients were pulmonary infiltrates seen without pleural or pericardial effusions. Steroids are widely used and there is prompt relief of symtoms, usually within 24-48 hr. Improvement is also reflected by normalization of the chest radiograph. In a recent trial, colchicine was shown to be efficacious in the prevention of the PPS.
References
1. Kaminsky ME, Rodan BA, Osborne DR, Chen JT, Sealy WC, Putman CE. Postpericardiotomy syndrome. AJR Am J Roentgenol 1982; 138:503-508.
2. Engle MA, McCabe JC, Ebert PA, Zabriskie J. The Postpericardiotomy syndrome and antiheart antibodies. Circulation 1974; 49:401-406.
3. Eguchi T, Yoshida K, Hamanaka K, Kurai M. Colchicine as an effective treatment for postpericardiotomy syndrome following a lung lobectomy. Interact Cardiovasc Thorac Surg 2010; 11:869-871.
Keywords
pericardium, non-infectious inflammation, inflammation,

No. of Applicants : 91

▶ Correct Answer : 52/91,  57.1%
  • - Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seongn Jong Yun
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - Government Medical College, Nagpur, India , India Krishna Prasad Bellam
  • - Hanam sungshim hospital , Korea (South) CHANG IL KIM
  • - Maimonides Medical Center , United States naomi twersky
  • - James Paget Hospital , U.K , United Kingdom nabil mahmood
  • - UWO , Canada S Lee
  • - SMC , Korea (South) Yi Kyung Kim
  • - Kurashiki Seijin-byo Center , Japan Akihiro Tada
  • - aarthi scans , India abirami mahadevan
  • - Korea university , Korea (South) Kun Woo Kang
  • - Saga University , Japan Ryoko Egashira
  • - CLCC , France nicolas gautier
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Asan Medical Center , Korea (South) Ji Eun Kim
  • - Asan Medical Center , Korea (South) Sang Min Lee
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Asan Medical Center , Korea (South) Hye Jeon Hwang
  • - Asan Medical Center , Korea (South) Eunyoung Kim
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Korea university anam hospital , Korea (South) Sung-Hye You
  • - Kohka Public Hospital , Japan Akitoshi Inoue
  • - Himeji St.Mary Hospital , Japan Yuichiro Kanie
  • - IRSA , France, Metropolitan BIGOT
  • - Hanyang University Hospital , Korea (South) Yo Won Choi
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - Toranomon Hospital , Japan Takana Yamakawa
  • - XiangYa hospital , China Xia Yu
  • - Seoul medical center , Korea (South) SungTaek Kim
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Chungbuk National University Hospital , Korea (South) Su Jeong Hyun
  • - Chungbuk national university hospital , Korea (South) Jisun Lee
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - National Taiwan University Hospital , Taiwan Li-Ta Keng
  • - Myongji hospital , Korea (South) Ji Ye Lee
  • - Suncheon Plus Medicine , Korea (South) Park Sang Hyun
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - All India Institute of medical sciences , India Justin Moses
  • - Private sector , Greece Vasilios Tzilas
  • - , Korea (South) Chan Park
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - fmmc , India subas kandimalla
  • - Chonnam national univ. hospital , Korea (South) Choi Seul-Gi
  • - Radnet Teleradiology Istanbul , Turkey Armagan Sarac
  • - CNUH , Korea (South) Hyedoo Jung
  • - Chonnam national university hospital , Korea (South) seo yeon Park
  • - Okayama university , Japan Mayu Uka
▶ Correct Answer as Differential Diagnosis : 6/91,  6.6%
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Montreal , Canada Drago Le King
  • - CHRU Lille , France Paul Lebert
  • - Alswaida- zaid alsherity hospital , Syria jehad alakabani
  • - Chonnam university hospital , Korea (South) Park young
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
▶ Semi-Correct Answer : 1/91,  1.1%
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
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