[ Pulmonary, Critical Care, and Sleep Pearls ]

A 35-Year-Old Woman With Acute

Pleuritic Chest Pain and an Unusual
Mediastinal Opacity
Camille Simon; Cécile Lorek, MD; Camille Boularan, MD; and Clara Fontaine-Delaruelle, MD

CASE PRESENTATION: A 35-year-old woman came to the ED following 2 days of chest pain.
She was a nonsmoker, taking no medications, and not using a contraceptive pill. The patient
had no history of recent travel but had given birth (full-term pregnancy) 4 months earlier.
She described nonradiating, left-sided pleuritic chest pain with no associated dyspnea, cough,
sputum, or sweating. CHEST 2019; 155(1):e17-e20

Physical Examination Findings

The patient had normal and symmetrical BP, a regular
pulse rate of 95 beats/min, 98% oxygen saturation on
ambient air, a respiratory rate of 16 breaths/min, and no
fever. Cardiopulmonary auscultation was normal, there
was no pericardial friction rub, no sign of cardiac failure,
and no sign of DVT.

Diagnostic Studies
The patient’s ECG was normal. On laboratory tests, the
WBC count was 11,480/mm3 (57% neutrophils),
C-reactive protein was 78 mg/L (normal, < 5 mg/L),
troponin was undetectable, and D-dimer level was
660 ng/mL (normal, < 500 ng/mL). The posterior-
anterior chest radiograph was normal, but the lateral
view revealed a small left pleural effusion with a
retrosternal mass (Fig 1). Considering the postpartum
context and mildly elevated D-dimer level, we
performed a chest CT angiography. The radiologist
found no pulmonary embolism but did describe a fatty
lesion in the left cardiophrenic angle surrounded by
inflammatory tissue and associated with small pleural Figure 1 – Lateral chest radiography: the arrow is pointing to the ret-
effusion (Fig 2). An echocardiogram was normal. rosternal mass; the arrowheads are pointing to the pleural effusion.

AFFILIATIONS: From the Université Claude Bernard Lyon 1
(Ms Simon and Dr Fontaine-Delaruelle), Pierre Bénite, France; and
Service de Pneumologie Aigue Spécialisée et Cancérologie Thoracique
(Ms Simon and Dr Fontaine-Delaruelle), centre hospitalier Lyon Sud,
Hospices civils de Lyon, Pierre Bénite, France; Service de Pneumologie
(Dr Lorek) and Service de Radiologie (Dr Boularan), Centre
Hospitalier d’Ardèche Méridionale, Aubenas, France.
CORRESPONDENCE TO: Clara Fontaine-Delaruelle, MD, Service de
Pneumologie Aigue Spécialisée et Cancérologie Thoracique, Centre
hospitalier Lyon Sud,165 chemin du grand Revoyet, 69495 Pierre
bénite CEDEX, France; e-mail: clara.fontaine-delaruelle@chu-lyon.fr
Copyright Ó 2018 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
DOI: https://doi.org/10.1016/j.chest.2018.07.036

chestjournal.org e17
 What is the diagnosis?

Figure 2 – Chest CT angiography showing a fatty lesion in the left

cardiophrenic angle (arrow) surrounded by inflammatory tissue and
associated with a small pleural effusion (arrowhead).

e18 Pulmonary, Critical Care, and Sleep Pearls [ 155#1 CHEST JANUARY 2019 ]
 pericardium (on CT imaging for these latter factors) has
Diagnosis: Epipericardial fat necrosis. been suggested as a diagnostic criterion.
Since 2005, the treatment of EFN has been based on
Discussion
nonsteroidal antiinflammatory drugs (NSAIDs) with CT
Epipericardial fat necrosis (EFN) was described for the
imaging follow-up (4-8 weeks following diagnosis). This
first time in 1957. The entity causes chest pain but
conservative treatment (preventing unnecessary surgery)
garners little attention in the literature, making its
is made possible by CT technologies, which can
frequency difficult to estimate. However (and as an
eliminate alternate diagnoses such as liposarcomas.
illustration), in a retrospective single-center study,
approximately 2% of patients who underwent CT scans To potentially reduce patient exposure to radiographs,
for chest pain had EFN. Furthermore, this disease may ultrasonography may also be useful for the diagnosis and
be frequently misdiagnosed. Indeed, CT scans may not follow-up of EFN. An ultrasound examination can show
be performed for all patients with chest pain, especially a hyperechoic mass or nodule in the epipericardial fat
when results of physical examinations, ECGs, and delimited by a hypoechoic halo with increased
posterior-anterior chest radiographs are normal. echogenicity of adjacent adipose tissue.
Moreover, even when CT scans are done and meet EFN
EFN is a benign condition. The pain associated with it
criteria, radiologists suggest the correct diagnosis in only
disappears within a few days of initiation of NSAID
27% of cases.
treatment, and the abnormalities seen on CT imaging
Fat necrosis is described much more frequently in progressively decrease over the following weeks. It is
locations other than the chest. It is frequently thus important for clinicians, radiologists, and thoracic
observed in the breast and as a cause of abdominal surgeons to correctly diagnose EFN so as to avoid
pain in epiploic appendagitis. The physiopathology of unnecessary diagnostic—and especially surgical—
the epipericardial version remains debated. Suggested procedures.
mechanisms include torsion of a vascular pedicle, as
in epiploic appendagitis, and increased intrathoracic Clinical Course
pressure, resulting in elevated capillary pressure and
Because we suspected pericarditis without pericardial
hemorrhagic necrosis. The study patient’s pregnancy,
effusion in this patient, our initial treatment choice
which had come to term 4 months prior to the
was aspirin. This latter proved effective, and thus we
present diagnosis, could have created important
did not change over to NSAIDs. A CT scan
variations in intrathoracic pressure, leading to this
performed 2 weeks following the diagnosis revealed
type of lesion. However, we emphasize that this
almost complete regression of the anterior
reasoning is only a hypothesis on our part; to our
mediastinal mass and resorption of the pleural
knowledge, no cases of EFN during pregnancy or the
effusion (Fig 3).
postpartum period have been reported in the
literature. EFN is described pathologically as fat
necrosis with an inflammatory reaction that varies
according to the age of the lesion. Later, it resolves
into scar tissue or becomes surrounded by a dense
collagenous capsule.
EFN presents most frequently as isolated pleuritic chest
pain with no associated life-threatening manifestations
such as oxygen desaturation and without abnormalities
observed on clinical examination or on the ECG.
Laboratory results are often normal except for D-dimer
levels and sometimes a systemic inflammatory reaction,
probably due to acute necrosis. Chest radiographs may
be normal during the first few days but show
abnormalities (paracardiac density) later in the course of
Figure 3 – Chest CT angiography 2 weeks later: the lesion in the left
disease. The triad of chest pain, an encapsulated fatty cardiophrenic angle (arrow) has almost completely regressed. There is no
lesion with dense strands, and thickening of the pleural effusion.

chestjournal.org e19
Clinical Pearls
1. EFN is a frequently misdiagnosed condition causing
isolated acute pleuritic chest pain.
2. The diagnosis is established via a CT scan, which will
show a characteristic, round, fatty lesion in the ante-
rior mediastinum surrounded by inflammatory tissue
and an associated small pleural effusion.
3. The emergence of ultrasound in lung diseases could
spare patients from radiograph exposure.
4. Treatment calls simply for the administration of
NSAIDs and offers an excellent prognosis.
5. Surgery is of no use for the diagnosis and treatment of
EFN.
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to
CHEST the following: C. S. reports nonfinancial support from Merck
Sharp & Dohme, outside the submitted work. C. F.-D. reports
nonfinancial support from Merck Sharp & Dohme, Novartis, and Laidet
Medical, outside the submitted work. None declared (C. L., C. B.).
e20 Pulmonary, Critical Care, and Sleep Pearls
Other contributions: The proofreading of this article was supported
by the Bibliothèque Scientifique de l’Internat de Lyon and the Hospices
Civils de Lyon. CHEST worked with the authors to ensure that the
Journal policies on patient consent to report information were met.
Suggested Readings
Paling MR, Williamson BR. Epipericardial fat pad: CT findings.
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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):1234-1236.
Pineda V, Andreu J, Cáceres J, Merino X, Varona D, Dominguez-
Oronoz R. Lesions of the cardiophrenic space: findings at cross-
sectional imaging. Radiographics. 2007;27(1):19-32.
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):337-341.
Giassi K de S, Costa AN, Bachion GH, et al. Epipericardial fat
necrosis: an underdiagnosed condition. Br J Radiol. 2014;87(1038):
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Díaz J, Alegría J, Pérez D, Medina C. Epipericardial fat necrosis:
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Giassi KS, Costa AN, Bachion GH, Kairalla RA, Filho JR. Epipericardial
fat necrosis: who should be a candidate? AJR Am J Roentgenol.
2016;207(4):773-777.
[ 155#1 CHEST JANUARY 2019 ]