Epipericardial fat necrosis: Uncommon cause of acute pleuritic chest pain

Abstract

Epipericardial fat necrosis (EPFN) is a rare cause for acute chest. We describe the case of a previously healthy 25-year-old man who presented with sudden onset of left-sided chest pain. Laboratory values showed only mildly elevated d-dimer and electrocardiogram was normal. However, subsequent CT angiogram of the chest revealed fat necrosis in the epipericardial fat, characteristic for EPFN, for which the patient was treated with nonsteroidal anti-inflammatory drug. This case highlights the importance of radiologists to consider the prospect of EPFN in the differential diagnosis of acute chest pain as correct diagnosis allows for conservative management and avoidance of more aggressive techniques in symptomatic patients.

Epipericardial fat necrosis: an uncommon self-limiting cause of pleuritic chest pain

“…3,5,6 The patient may demonstrate diaphoresis, tachycardia or tachypnea; otherwise, the clinical examination is often noncontributory, with negative findings on cardiopulmonary and abdominal assessment. 1,7 Tenderness to palpation over the left anterior chest may be present. 6 The presence of a friction rub on auscultation has been described in some patients with a coexisting pericarditis.…”

“…6 The presence of a friction rub on auscultation has been described in some patients with a coexisting pericarditis. 6,7 Bloodwork and initial imaging are often noncontributory. 5 Troponins should remain negative.…”

“…7 Mild elevation in inflammatory markers may be present, as was shown in our case. 7 Initial chest radiography may be normal. If inflammation in the epipericardial fat is advanced, a circumscribed density can be seen within the fat at the cardiophrenic angle, although this is nonspecific.…”

“…Similar fat stranding has also been reported with fat necrosis occurring in omental torsion and epiploic appendagitis, making it difficult to distinguish the lesions from a more serious process in the absence of awareness of this benign condition. 7 Since 1957, cases of epipericardial fat necrosis have primarily been managed surgically. 8 As awareness that the condition is usually benign increased in the early 21st century, nonsurgical management of cases has been described.…”

“…Nonsteroidal anti-inflammatory medications and follow-up are often sufficient, with symptoms typically resolving within a few days. 5,7,8 Follow-up CT studies show involution of the findings over the course of weeks to months. 3,8 In rare cases, where the definitive CT appearance remains uncertain, more advanced imaging modalities such as magnetic resonance imaging, and even exploratory thoracotomy, have been used to exclude underlying malignancy.…”