Epipericardial fat necrosis, the overlooked culprit behind chest pain: a case report

BACKGROUND: Epipericardial fat necrosis is a rare, self-limiting cause of acute chest pain, which is often misdiagnosed owing to its nonspecific presentation and it being a relatively unknown entity to radiologists. CASE PRESENTATION: A 58-year-old White Swiss male presented with pleuritic, position-dependent chest pain, dyspnea, and transient left-arm paresthesia. Initial workup showed mildly elevated troponins (38 ng/l) and left-sided pleural effusion on X-ray. Computed tomography imaging revealed an ovoid epipericardial fat lobule with surrounding edematous infiltration, consistent with epipericardial fat necrosis as the pain's cause. Conservative management resulted in symptom resolution and discharge without complications. DISCUSSION: Epipericardial fat necrosis typically presents as an intense, pleuritic chest pain, often mimicking serious conditions such as pulmonary embolism or acute coronary syndrome. Computed tomography is the diagnostic modality of choice, frequently revealing a fat-density lesion with surrounding soft-tissue inflammation. Magnetic resonance imaging findings may include a fat-intensity lesion with inflammatory margins. While pathological evaluation is rarely needed, epipericardial fat necrosis may mimic malignancies, warranting careful follow-up in case of doubt. Treatment is conservative, focusing primarily on nonsteroidal anti-inflammatory drugs, and symptoms usually resolve within a week. CONCLUSION: Epipericardial fat necrosis, though rare, should be considered in patients with unexplained chest pain and characteristic imaging findings. Awareness among radiologists and emergency clinicians is essential for accurate diagnosis and to avoid invasive interventions.