Description

An elderly woman with asthma presented with symptoms of dyspepsia. Gastroscopy showed a hiatus hernia with large gastric ulcer. She was treated with proton pump inhibitors and improved symptomatically. Four weeks later, she developed sudden-onset breathlessness and wheeze. The patient was afebrile. Initial examination revealed tachycardia, tachypnoea and severe bronchospasm. No evident focus of sepsis was found at this point, and patient improved after treatment with bronchodilators. A day later, however, patient's breathlessness worsened and a chest x-ray revealed a pneumopericardium. Echocardiogram showed the presence of pneumopericardium, with no evidence of tamponade (figure 1). This was further confirmed by CT scan of the chest, which revealed pneumopericardium. However, pericardiocentesis revealed the presence of pus in addition to air. Pus grew Enterococcus fecalis. An endoscopy was performed, which revealed an ulcer in the hiatus hernia perforating into the pericardial space. The poor general condition of the patient precluded surgical intervention and she passed away in spite of broad-spectrum antibiotics and drainage of pus in the pericardial sac.

Pyopneumopericardium is a serious condition that has a death rate of almost 100%.1 Surgery is the treatment of choice for pneumopericardium due to gastropericardial fistula regardless of the site of the fistula.2⇓

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Figure 1

Pyopneumopericardium.