Image Diagnosis: Pericardial Cyst
A 50-year-old woman presented to the Emergency Department with 5 days of diffuse abdominal pain and constipation. An acute abdominal series was obtained to rule out a bowel obstruction during her workup. The upright chest image of the acute abdominal series demonstrated a smoothly rounded mass at the right cardiophrenic angle (Figure 1). This incidental finding was seen in more detail on her computed tomography scan of the abdomen and pelvis as a sharply demarcated, thin-walled, fluid-filled lesion measuring 7.7 cm in diameter (Figure 2). These radiographic findings were consistent with a large pericardial cyst. Pericardial cysts are rare, usually benign congenital anomalies.1,2 The vast majority are asymptomatic and are usually found incidentally on chest radiographs, computed tomography scans, magnetic resonance images, or echocardiography. They represent 6% of mediastinal masses and 33% of all mediastinal cysts.1 Large pericardial cysts may cause compression on adjacent structures and organs, resulting in dyspnea, chest pain, or persistent cough.3 There have been reports of cyst rupture, cardiac compression, atrial fibrillation, and even sudden cardiac death from these cysts, although these complications are uncommon.4,5 Recent case reports have shown that pericardial cysts can sometimes be confused with a coronary artery aneurysm, dextrocardia, malignancy, and even pneumonia.6-9 When surgery is required to remove them, video-assisted thoracoscopic surgery, thoracotomy, median sternotomy, and ultrasound-guided percutaneous aspiration have all been used with success.3 In this particular case, the patient was found to have colon cancer and a mass that was causing a bowel obstruction, independent of the pericardial cyst. A sigmoid colectomy was performed and the patient is undergoing further evaluation for the malignancy. The patient was asymptomatic from her pericardial cyst and nothing further was done from that standpoint.
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3. Najib MQ, Chaliki HP, Raizada A, Ganji JL, Panse PM, Click RL. Symptomatic pericardial cyst: a case series. Eur J Echocardiogr 2011 Nov;12(11):E43. DOI: http://dx.doi.org/10.1093/ejechocard/jer160
4. Vlay SC, Hartman AR. Mechanical treatment of atrial fibrillation: removal of pericardial cyst by thoracoscopy. Am Heart J 1995 Mar;129(3):616-8. DOI: http://dx.doi.org/10.1016/0002-8703(95)90293-7
5. Fredman CS, Parsons SR, Aquino TI, Hamilton WP. Sudden death after a stress test in a patient with a large pericardial cyst. Am Heart J 1994 Apr;127(4 Pt 1):946-50. DOI: http://dx.doi.org/10.1016/0002-8703(94)90572-X
6. Chauhan A, Musunuru H, Hallett RL, Walsh M, Szabo S, Halloran W. An unruptured, thrombosed 10 cm right coronary artery aneurysm mimicking a pericardial cyst. J Cardiothorac Surg 2013 Jan 7;8:2. DOI: http://dx.doi.org/10.1186/1749-8090-8-2
7. Hamad HM, Galrinho A, Abreu J, Valente B, Bakero L, Ferreira RC. Giant pericardial cyst mimicking dextrocardia on chest X-ray. Rev Port Cardiol 2013 Jan;32(1):49-52. DOI: http://dx.doi.org/10.1016/j.repce.2013.01.004
8. Kumar S, Satija B, Mittal MK, Thukral BB. Unusual mediastinal dumbbell tumor mimicking an aggressive malignancy. J Clin Imaging Sci 2012;2:67. DOI: http://dx.doi.org/10.4103/2156-7514.103057
9. Forouzandeh F, Krim SR, Bhatt R, Abboud LN, Ramchandani M, Chang SM. Giant pericardial cyst presenting as pneumonia. Tex Heart Inst J 2012;39(2):296-7.