Case contributed by Maher Khazem


Status post right upper lobectomy with mediastinal lymph node dissection, with past medical history of SCC of lung.

Patient Data

Age: 50 years
Gender: Female

Radiolucency surrounding lateral heart border signifying pneumopericardium. Significant pneumothorax in right lung with chest tube in place. Bilateral pulmonary parenchymal opacities. Endotracheal tube in mid trachea. Sub-diaphragmatic enteric tube in place. Surgical clips in the right perihilar region. 

Case Discussion

This case is an impressive example of what pneumopericardium looks like on a chest x-ray. The radiolucent streak around the lateral border of the heart is air filling the pericardial sac. This outlines the border of the heart and you see a clear distinction between the sac the air filling, and the heart itself. 

Pneumomediastinum is a rare but surgical emergency and surgery should be consulted immediately to find and treat the cause. Failure to do so can lead to increased pressure on the heart and eventually tamponade and pump failure. 

Though this case was most likely due to her lobectomy and cardiothoracic surgery, it is still important to make the diagnosis and explore etiologies (surgery, trauma, PPV, fistula). 

Treatment may be pericardiocentesis or supportive if there is no continuous leakage of air and the cardiovascular system is stable. 

Continuous diaphragm sign is the appearance of the central portion of the diaphragm clearly in a chest x-ray, usually obscured by the heart. The air gives a radiolucency which can let you appreciate the entire diaphragm. For this reason, continuous diaphragm sign can be seen in pneumoperitoneum (lucency below the diaphragm) or pneumopericardium (lucency above diaphragm).

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