A 40 year old female with hepatitis C, AIDS, and a heavy smoking history was admitted to our hospital where computed tomography of the chest revealed a left perihilar mass with mediastinal and hilar lymphadenopathy; also noted was a moderate-sized pericardial effusion. Fiberoptic bronchoscopy was performed and two nondiagnostic transbronchial biopsies were obtained. Transthoracic echocardiography done postprocedure revealed interval increase in the size of the pericardial effusion. Elective right heart catheterization and pericardiocentesis were performed in order to avert tamponade and to provide an adequate pathological specimen for diagnosis. Approximately 800 mL of bloody pericardial fluid was returned, and a pericardial drainage catheter was left in place. As documented by pressure measurements, the effusion was hemodynamically insignificant at the time of aspiration. The next morning the patient was noted to be tachypneic, tachycardic, and hypotensive. Aspiration of the pericardial catheter returned approximately 30 mL serosanguinous fluid and then 200 mL of air. The patient experienced immediate symptomatic and hemodynamic improvement. Review of a chest radiograph obtained earlier that morning revealed a large pneumopericardium. Pneumopericardium is a disorder most commonly associated with blunt or pentrating trauma to the chest wall. Other causes of pneumopericardium are rare, but can be just as life-threatening. Endoscopic procedures, the Heimlich and Valsalva maneuvers, pacemaker lead placement, and coronary artery bypass all have strong associations with pneumopericardium. Less frequent causes include cocaine use, diverticulitis, mechanical ventilation, continuous positive airway pressure ventilation, gastropericardial and enteropericardial fistulas, bronchogenic cancers, and gas-producing pericardial infections. One procedure that has not previously been reported to lead to pneumopericardium or air tamponade is fiberoptic bronchoscopy with transbronchial biopsy. While there are multiple case reports documenting the association between bronchogenic cancer and pneumopericardium, a search of the literature did not reveal an instance of the development of a broncho-pericardial fistula following transbronchial biopsy.
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