Chandrike Ponnamperuma

Eranda Chamara Ratnayake

Nilanthi Fernando

Niroshan Lokunarangoda

Sandamali Premaratne

Sanduni Fernando

W Samuel Santharaj

BMC Research Notes

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Pneumopyopericardium mimicking an inferior ST elevation myocardial infarction with regional electrocardiogram changes: a case report

Ratnayake et al. BMC Research Notes  (2015) 8:173 
DOI 10.1186/s13104-015-1143-7CASE REPORT Open AccessPneumopyopericardium mimicking an inferior ST
elevation myocardial infarction with regional
electrocardiogram changes: a case report
Eranda Chamara Ratnayake*, Sandamali Premaratne, Niroshan Lokunarangoda, Sanduni Fernando,
Nilanthi Fernando, Chandrike Ponnamperuma and W Samuel SantharajAbstract
Background: Pneumopyopericardium is a rare disease with poor prognosis. The usual presentation is with fever,
shortness of breath and haemodynamic compromise. The Electrocardiogram changes associated with this disease
entity would be similar to pericarditis such as concave shaped ST elevations in all leads with PR sagging.
Pneumopyopericardium mimicking an acute ST Elevation Myocardial Infarction, with regional Electrocardiogram
changes has hitherto not been described in world literature.
Case Presentation: We describe the case of a 48 year old native Sri Lankan man, presenting with chest pain and
Electrocardiogram changes compatible with an Acute ST Elevation Myocardial Infarction, subsequently found to
have Pneumopyopericardium secondary to an oesophageal tear. Retrospective history revealed repetitive vomiting
due to heavy alcohol consumption, prior to presentation. It unfortunately led to a fatal outcome.
Conclusion: Pneumopyopericardium may mimic an acute ST elevation myocardial infarction with associated
regional Electrocardiogram changes. A high degree of suspicion should be maintained and an adequate history
should always be obtained prior to any intervention in all ST Elevation Myocardial Infarction patients.
Keywords: Pneumopyopericardium, Pneumopericardium, Mediastinitis, Myocardial infarction, STEMIBackground
Cardiovascular disease is the leading cause of mortality
worldwide [1]. Pericardial disease and effusions account
for approximately 6-7% of cardiac disease in the adult
population [2] of which Pneumopyopericardium is a sel-
dom reported disease entity. It was first described by
Hallin in 1863 [3] and since then less than 20 cases have
been reported in world literature. The presentation is
often preceded by a traumatic or non-traumatic ulcer-
ation of the oesophagus or stomach. Presenting symp-
toms of pneumopyopericardium include but are not
limited to fever, pleuritic chest pain, shortness of breath
associated with significant haemodynamic compromise
[4]. The commonest precipitating cause is a non-
traumatic oesophageal ulcer or carcinoma [4]. Electro-
cardiogram (ECG) changes associated with the disease* Correspondence: chamara.ratnayake@gmail.com
Institute of Cardiology, National Hospital of Sri Lanka, Regent Street,
Colombo 7, Sri Lanka
© 2015 Ratnayake et al.; licensee BioMed Cent
Commons Attribution License (http://creativec
reproduction in any medium, provided the or
Dedication waiver (http://creativecommons.or
unless otherwise stated.are comparable to generalized pericarditis, with concave
shaped ST elevations in all leads with PR segment sagging
[5]. A presentation mimicking an Acute ST Elevation
Myocardial Infarction (STEMI) with regional electrocar-
diogram changes has hitherto not been described in pub-
lished world literature.Case presentation
A 48 year old Sinhalese man from Chillaw, Sri Lanka
presented to his local hospital with a history of sudden
onset retrosternal chest pain, shortness of breath and
sweating. He was a heavy alcohol abuser, consuming 10
Units of Local Arrack (Ethanol) on a daily basis with oc-
casional use of illicit alcohol (Methanol). An ECG taken
at the local hospital is seen in Figure 1. It was suggestive
of an Acute Inferior ST Elevation Myocardial Infarction.
In the absence of any known complications and as inter-
ventional facilities were not available at that centre, he
was thrombolysed with IV streptokinase. As the patientral. This is an Open Access article distributed under the terms of the Creative
ommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
iginal work is properly credited. The Creative Commons Public Domain
g/publicdomain/zero/1.0/) applies to the data made available in this article,
Figure 1 Electrocardiogram – Initial Electrocardiogram of the patient
showing ST elevations in the Inferior Leads with Reciprocal ST depressions
in lateral leads.
Figure 2 Chest X-Ray – Chest X-Ray – Anterior-Posterior View of the
patient showing air and fluid around the heart.
Ratnayake et al. BMC Research Notes  (2015) 8:173 Page 2 of 4had persistent chest pain and unresolved ST segment
changes, he was transferred to the National Hospital of
Sri Lanka for further management. A retrospective his-
tory revealed the patient had repetitively vomited prior
to his initial presentation preceded by heavy alcohol
consumption. Examination revealed muffled heart sounds
and a pericardial friction rub. An immediate bedside 2 Di-
mensional Echocardiogram was performed which had
poor echo windows but a moderate pericardial effusion
was identified with no clear evidence of tamponade. There
was no significant regional wall motion abnormalities. A
Chest X-Ray – Antero-Posterior View was performed
(Figure 2) which was followed by a Contrast Computer
Tomography Chest (Figure 3). An urgent pericardial aspir-
ation evacuated 800 millilitres of frank pus and a diagnosis
of pneumopyopericardium was made. In search of a
possible aetiology, a Gastrograffin study was performed
(Figure 4). An immediate surgical referral was made
which was followed by endoscopic covered stent place-
ment. Intravenous meropenem was commenced pending
culture reports. Troponin I titres were negative. A coron-
ary angiogram was not performed on the patient due to
high risk and haemodynamic instability. Unfortunately,two days after treatment at the coronary care unit, the
patient developed a cardiac arrest and expired.Discussion
Pneumopyopericardium is an uncommon disease entity,
with less than 20 cases reported to date in world litera-
ture. Our case provides insight in to a rare and never be-
fore described presentation mimicking an acute ST
elevation myocardial infarction with regional electrocar-
diogram changes. Although falsely managed as an acute
coronary syndrome initially, a diagnosis of pneumopyo-
pericardium was retrospectively made. A focused history
prior to intervention may have predicted the disease, as
the patient complained of persistent vomiting secondary
to heavy alcohol abuse. Consistent with other reported
cases, this patient was also found to have an oesophageal
rupture. A possible cause for acute ST segment eleva-
tions in this scenario could be a localized myopericardi-
tis, which has been reported previously [5]. Regional ST
segment changes are known to occur in this circum-
stance, contrary to the generalized ECG changes associ-
ated with a more extensive pericarditis. A coronary
angiogram was not performed on this patient to assess
his coronary arteries as he was unstable haemodynamic-
ally and carried high mortality risk. However, an acute
coronary syndrome secondary to significant coronary ar-
tery disease could be excluded by the negative Troponin
titre and lack of significant regional wall motion abnor-
malities on 2 Dimensional echocardiography. Although
timely intervention was initiated with a covered stent
placed at the ruptured part of the oesophagus by the
surgical team, overwhelming sepsis took over and the
patient eventually had a fatal outcome. Poor prognosis
Figure 3 Contrast Computer Tomography Chest – Contrast Computed Tomography Chest showing air and fluid around the heart.
Figure 4 Gastrograffin Test – Gastrograffin test showing lower
oesophageal rupture and covered stent placement.
Ratnayake et al. BMC Research Notes  (2015) 8:173 Page 3 of 4following pneumopyopericadium is well documented in
world literature [6].
Conclusions
Pneumopyopericardium may present as an acute ST ele-
vation myocardial infarction. A high degree of suspicion
should be maintained in the correct clinical setting. The
prognosis remains poor, despite maximal medical and
surgical management for the condition.
Consent
Written informed consent was obtained from the patient
for publication of this Case Report and any accompanying
images. A copy of the written consent is available for re-
view by the Editor-in-Chief of this journal.
Abbreviations
ECG: Electrocardiogram; STEMI: ST Elevation Myocardial Infarction; CXR: Chest
X-Ray; CT: Computed tomography.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ECR carried out the literature search and drafted the manuscript; WSS did
the critical revision for important intellectual content in the manuscript and
given the final approval of the version to be published; NL, SP, SF, NF and
CP helped substantially in literature search and drafting the manuscript. All
authors read and approved the final manuscript.
Ratnayake et al. BMC Research Notes  (2015) 8:173 Page 4 of 4Authors’ information
ECR is a Senior Registrar in Cardiology at National Hospital of Sri Lanka.
NL is a Senior Registrar in Cardiology at National Hospital of Sri Lanka.
SP is a Senior Registrar in Cardiology at National Hospital of Sri Lanka.
SF is a Research assistant attached to the Institute of Cardiology, National
Hospital of Sri Lanka.
NF is a Consultant Neurologist and Senior Lecturer in Pharmacology at the
Faculty of Medical Sciences, University of Sri Jayawardenapura, Sri Lanka.
CP is a Resident Cardiologist at the National Hospital of Sri Lanka.
WSS is a Consultant Cardiologist at the National Hospital of Sri Lanka.
Acknowledgements
The authors thank the departments of radiology, microbiology and surgery
at the National Hospital of Sri Lanka for providing help in diagnosing and
managing the patient mentioned in the case report
Received: 25 December 2014 Accepted: 22 April 2015
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(Stockh). 1983;24(4):305–8.Submit your next manuscript to BioMed Central
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Pneumopyopericardium mimicking an inferior ST elevation myocardial infarction with regional electrocardiogram changes: a case report

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