Isolated tension pneumopericardium in a case of acute lymphoblastic leukemia

A 6-year-old female suffering from acute lymphoblastic leukemia, who was on her induction phase regimen presented with sudden onset of NYHA class IV shortness of breath to emergency department at Osmania General Hospital, Hyderabad in September 2012. On examination she was febrile with a feeble pulse, had low intensity heart sounds and was rapidly breathing with bronchial breath sounds over her lung fields. Her chest X-ray revealed a huge amount of air in pericardial space causing compression over heart as seen in Fig. 1. A CT scan of thorax showed the same in Fig. 2. There is a radioopaque mass in left lung suggestive of fungal ball appearance of pulmonary Aspergillosis (Fig. 3). Fig. 1 Chest X-ray showing pneumopericardium. Fig. 2 CT image showing isolated pneumopericardium. Fig. 3 Left lung showing large cavity filled with mass. Patient underwent pericardiocentesis via sub xiphoid approach and a 6 Fr pigtail catheter was inserted and the air was aspirated (Fig. 4) with underwater seal and was put on intravenous antibiotics including antifungal medication. The patient improved symptomatically. Fig. 4 Post pericardiocentesis with pigtail insitu. Pneumopericardium is a well recognized entity known to occur in a number of conditions like post cardiopulmonary resuscitation, post pericardial aspiration, post cardiac surgery, trauma either blunt or penetrating injuries to chest, in patients with esophageal rupture. Most of these patients have associated pneumomediastinum. A few radiological signs like small heart sign,1 continuous hemi diaphragm sign2 have been described. This is one of the rare cases reported with isolated tension pneumopericardium with out accompanying pneumomediastinum in a cancer patient with a superimposed probable fungal infection.3