A 35-Year-Old Woman With Acute Pleuritic Chest Pain and an Unusual Mediastinal Opacity

Abstract

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.

Epipericardial Fat Necrosis: A Case Report and a Review of the Literature

“…Slightly elevated D-dimer, CRP, and/or white blood cell count is relatively common in EFN, 2 , 6 - 10 which also is true for most of its differentials. Echocardiogram is usually normal, but nonspecific ECG changes such as ST-T wave abnormalities are reported.…”

“…Recommendations for treatment and follow-up include a shorter period of nonsteroidal anti-inflammatory drugs (NSAIDs) 3 , 10 , 14 , 20 and a follow-up CT scan in 4 to 8 weeks to confirm healing and definitely exclude malignancies. 3 , 9 Most patients are pain free within the first week 1 , 14 , 17 , 21 and serial CT has shown partial or full resolution after 2 to 12 weeks. 8 , 9 , 11 , 22 , 23 Relapses are sometimes seen, 17 , 19 , 21 , 22 but reports of these are rare and prognosis is usually very good.…”

“…In the few cases performed, TTE in EFN are reported as normal, despite a positive chest CT. 3 , 6 , 9 , 10 , 22 It has been suggested that failure to identify the epipericardial fat pad necrosis in EFN might be due to lung artefacts or the patient being unable to position himself optimally for the examination due to pain. 6 An exception was a report where both transthoracic and transoesophageal echocardiography revealed a paracardiac mass with a calcified rim, suggestive of chronic EFN.…”

Young women with severe chest pain

“…Mediastinal fat necrosis, also referred to as "epipericardial" fat necrosis, is a rare, self-limiting condition that can mimic the presentation of both acute coronary syndrome and PE. 1,2,4 The presentation usually involves acute pleuritic chest pain in a previously healthy patient. 2,3 The left side is more frequently affected, 2,3,6 possibly due to the greater amount of left-sided fat compared to the right.…”

“…The etiology is unclear but several mechanisms have been postulated including torsion of a vascular pedicle, an anatomic structural abnormality of the adipose tissue resulting in vulnerability to heartbeat-induced trauma, or increased intravascular pressure from a Valsalva maneuver leading to injury and hemorrhage of the adipose tissue associated with the pericardium. [1][2][3][4][5] Obesity could be a risk factor as well. 3,6 Prior to 2000, treatment frequently included either thoracotomy or minimally invasive surgery to remove and biopsy the soft tissue and fat-containing density (Figure 1) to evaluate for malignancy.…”