1Central Laboratory Tokyo Medical College Hospital, 2Second Department of Internal Medicine Tokyo Medical College Hospital, 3Third Department of Surgery Tokyo Medical College Hospital, 4Department of Clinical Pathology Tokyo Medical College Hospital
Two-dimensional echocardiography revealed pneumopericardium in a case of esophageal carcinoma (stage IV). The patient, a 79-year-old man, had dysphagia. Gastric endoscopy showed the lesion to be a moderately differentiated squamous cell carcinoma. The lesion responded to cobalt 60 Gy radiation therapy as the dysphagia improved. On the day on which the patient was to be discharged, however, acute backache developed and the patient went into shock. Results of baseline examinations were systolic pressure, 60 mm Hg; tachycardia, 160 beats/min; ECG, low voltage indicative of atrial fibrillation, and elevated ST in leads I , II, and V3-6. A roentgenogram showed a linear shadow in the outer border of the fourth intercostal space. Pneumopericardium was suspected, and an echo-free space underlying the pericardium was found on two-dimensional echocardiographic examination. Air in the pericardium overlying the right ventricle produced the high-density echo band known as the air-gap sign. This high-density echo was most clearly observed during the systolic phase of cardiac contraction. Severe hypokinesis of both the right and left ventricles was observed. The inferior vena cava appeared motionless, and there was no tamponade type pendular motion. The patient's condition improved symptomatically after effusion and air were drained. In this rare case, the esophageal carcinoma had invaded the adjoining pericardium, creating a fistula. In cases of chest trauma, as well as in the present case of cardiac invasion by disease in adjoining organs, the possibility of the presence of air in the pericardium should not be overlooked. Presence or absence of air can be confirmed by two-dimensional echocardiography.