Epipericardial fat necrosis

Last revised by Dr Mostafa El-Feky on 07 Aug 2021

Epipericardial fat necrosis (also sometimes purely categorized as pericardial fat necrosis or epicardial fat necrosis) is a rare self-limiting cause of acute pleuritic pain in an otherwise healthy individual, without fever or cough. It occurs external to the pericardium.

The patient presents with acute pleuritic chest pain that may mimic other cardiopulmonary causes. It is a self-limiting pain, ipsilateral to the lesion, which is more commonly on the left side (can be right-sided). The pain may persist for several weeks. Syncope, tachycardia and dyspnea have also been reported. However cough and fever are not seen 4.

On physical examination, a pericardial friction rub may be heard.

Laboratory findings, including inflammatory markers, and ECG are usually normal.

The pathogenesis of pericardial fat necrosis is unknown. Some predisposing factors have been mentioned in the literature:

  • trauma
  • ischemia due to an acute torsion
  • high positioned pericardial fat
  • obesity
  • increased thoracic pressure related to the Valsalva maneuver may increase the capillary pressure, which leads to hemorrhagic necrosis

Typically, the chest radiograph is normal in the first 48-72 hours of the disease. Following on from this a characteristic opacity is always seen 4:

  • juxtacardiac mass-like opacity near the cardiophrenic angle with or without pleural effusion and ipsilateral to the chest pain
  • it always lies ventrally and invariably merges imperceptibly with the heart border
  • ovoid encapsulated mediastinal (pericardial) fatty lesion with soft tissue rim and intrinsic and surrounding soft tissue stranding
  • thickened adjacent epicardium
  • a pleural effusion may be present

Findings are similar to that observed with epiploic appendagitis and omental torsion in the peritoneal space.

Findings on MRI have been reported in two patients, with findings reflecting those on CT, i.e. a fatty lesion and internal soft tissue stranding 4.

It is thought to have been first described in 1957 by Jackson et al 4,8.

Conservative management with non-steroidal anti-inflammatory drugs (NSAIDs) and follow-up is usually performed. It is generally considered self-limiting. Historically, in the pre-CT era, many were removed due to concerns about malignancy 4.

Possible differential considerations include:

Initially, when the chest radiograph is normal, it is often mistaken for more serious diagnoses that present with acute chest pain:

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Cases and figures

  • Case 1
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  • Case 2: on CTPA
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  • Case 3
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  • Case 4
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