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Pericardio Peritoneal Communication—An Additional Etiologic Factor in Purulent Pericarditis
454
DEVIN AND MERDINGER REFERENCES
2
3 4
.'5 6
7
R
9
SHAW, R. R., P AULSON, D. L., KEE, J. L. , AND LOVETT, V. F .: Pr im ary pulmonary leiomyo sarcomas, J. Thorac . Cardiocasc. Surg., 41 :430, 1961. i\"Eu~r AX:-I, R.: Le iomyosarkom der lunge, Frankfurt. Z. Path. , 52 :576, 1938. HAVARD, C . W ., AND HA:-JnURY, \ V. J.: Leiomyosarcoma of th e lung, Lancet , 2:902, 1960. RA:-'ilALL, W . S., A:-''D BLADES, B. : Primary bronchiogeni c leiom yosarcoma, Arch . Path ., 42 :543, 1946. Hrcxs, H. G .: Bronchogenic leiomyosarcoma; Ca se report with necropsy findings , Dis . Ch est, .'32:338, 1957. Hosax, A., CHnISTE:-:S E:-J, A. H., A:-:D JA~rPLls , R. W . : Primary leiomyosarcoma of the lung. Case report. Dis. Ch est, 45 :420'5, 1964. TOCKEH, A. ~1. , DEHAAN, C. , A:>''D STOFER, B. E.: Primary pulmonary leiomyosarcoma, Dis. Chest , 31 :328, 1957. GLEXX, F ., A:>:D OKr:>:AKA, A. J.: The lung tumor of a virologist. A short case report of a rare tumor and a hit of m edical history. ]. Thorne . Cardiocasc. Surt;., 0'51 :4.'5 5, 1966. YACOl.'nJ AX, II .. COXXOl.LY. J. E., x xn WYLIE, R. H. : L eiomyosarcoma of the lung, Ann. Surg. , 147:116, 195R.
Reprint requests : Chief. Supply Division, VA Hospital , Topeka, 66622
Pericardio Peritoneal CommunicationAn Additional Etiologic Factor in Purulent Pericarditis*
!"r<;URE I. Chest x-ray Hlm, March 1, HJ61. .1 CIlI below hoth costal margins. On March 4 an l'nl ar gl·r1 ca rdiac sha d ow and a large abdom inal den sit y wa s see n tin the rovntgenogrum (F ig l ). Figurr- 2 shows comp res sio n of
Joseph D edll . M.D" and Walter F. Merdinaer , M.D., F.C .C .P.
The occurrence of a case in which purulent pericarditis occurred in conjunction with a peritoneal abscess indicates that an additional etiologic factor in purulent pericarditis may be communication between the pericardial and peritoneal cavities through a congenitally weakened portion of the diaphragm.
purulent pericarditis has heen discussed often in the medical literature. Factors concerning etiology have been listed in several papers. The occurrence of a case in which communication hetween the pericardial and the abdominal cavities was dem onstrated by perforation of a peritoneal abscess into the pericardium prompted this review of literature concerning this subject and forms the hasis for this report. CASE REPORT
A two-year-old hoy was admitted March 3, 1961 to Ch ildren's Hospital, San Diego, with complaints of anorexia, an emia and th e presence of an abdominal mass. Infancy had he en complicated b y recurrent bouts of staphylococcal infections in volving skin and respiratory syst em s. Upon examination, a tender mass was palpated in th e epigastrium
"From the Department of Surrery, University Hospital, San Diego County, University 0 California (San Diego) San Diego, C alifornia.
FrGUH E 2. Lateral abdominal x-ray film. March :2, 1961.
DIS. CHEST, VOL. 56. NO.5. NOVEMBER 1969
455
PERICARDIO PERITONEAL COMMUNICATION
C+-+-AU. OC.l
HEART
c.t F J(;UIIE 3. Chest x-ray film . March 5. 1961. th e s toma ch po ste riorly h y nn ah do minal ma ss, On March 5 d yspne a, cyanosis and a tachyca rdia of 120 /lIlinllle d evel op ed rap idl y. F igll n ' 3 sho ws an inc rease in th e ca rd ia c sizo. :\ suh seq ue nt p eri card ia! tap ohtninc d ,'iO ml wh itr . purulent fluid . T he co nd itio n improved some w hat. h nt th e followin g day ma rkt·d cyanosis, neck ve in di stention n nd ('\'idl' nc(' of ucutr - card iac ta m po na d e occ ur red , Le ft a lltcrinr th ora cot om y was perform ed a nd a peri cardiaI win d ow was crea ted follo wi ng deco mpression of a marke d ly d iskn(\ed peri cardium . As d eco mpres sion cn ntin ue r], sim nltnnoon s resolution of th e a bdomi nal mass occu rr ed . Ab dominal exp loration rr-veulrxl m ark ed hcp ntom c unly. a nd an abscess Ir in g uhovr- tlu- ldt lolx- of th e liver and ante rio r to th e stomach . Th is wa s d ra ined h )' means of slimp tuhe x, TI ll' organ ism was id" n lif1('d as Stap l, !/lncncc lIs aurcu s, coa gn lase posit in '. Fo llo wi n g a sto rm y postop e rat ive co ur se . tlu - eh il,1 improved anti w as dis ch ar g(·(1. Fi gHT(' 4 is Ill(' clu -st filill tak en june 19. HJIH . DlSCUSSIO~
A review of the embrvologic dev elopment of the
FI Gt:nE 4 . Ch est x-ray film.l nlle 19. 1961.
DIS. CHEST, VOL. 56. NO.5, NOVEMBER 1969
r.i
FIt: l'II ~:
Pallen).
:>. J),· \'(·lupn wnl o f sepu u u inl rnnsv" rsiull (a ft,· r
diaphragm and pericardium shows that the primitive coelom is divided hy three sets of partitions, Th e unpaired septum transversurn arises from a cranially located portion of mesoderm which und ergoes reversal of position. coming to fonn a transverse partition between the pleural and peritoneal cavities ( Fig 5 ). Thi s septum is imperfect as paired pleural canals course dorsally ab ove the septum on each side conn ecting the pleural and abdominal portions of the ~eneral coelom. The pleuro-peri -
FIGURE 6. Newborn diaphragm.
456
DIZADJI ET AL
toneal membranes supplement the septum transversum and complete the isolation of true pleural, pericardiaI and peritoneal cavities. I Defects in the diaphragm may occur, leading to herniation of abdominal contents. These are commonly at the site of the left pleuro-peritoneal membrane, the foramen of Bochdalek and at the foramen of Morgagni. To postulate the formation of a communication between the pericardium and the peritoneal cavity would necessitate this communication to arise from the unpaired portion of mesoderm forming the septum transversum, Such a communication has been reported only once in the world literature by O'Brien in 1939, reporting on an autopsy case of a 63-year-old Russian man," Numerous other reports have recorded defects in the diaphragmatic pericardium. These have all occurred in the anterior portion of the pericardium and have occurred in association with multiple anomalies, including defects of the upper abdominal wall, sternum and heart. H With knowledge of the embryologic peculiarities involving the peritoneal pericardial communication, several stillborn infants have been examined and the diaphragmatic portion of the pericardium and the diaphragm were closely examined. A constant feature of these dissections was the presence of a markedly thinned-out area in the mid-portion of the diaphragm. Such an area is demonstrated in Fig 6. CONCLUSION
Numerous authors have reviewed suppurative pericarditis and have included as etiologic factors septicemia, tuberculosis, bronchopneumonia, empyema, carcinoma and even perforation of a gastrojejunal ulcer into the pericardium.v'!" Other reports have indicated the associated presence of a peritoneal abscess. Pericarditis or pleural effusion in these instances is believed secondary to perforation of the abscess through the diaphragm. No mention has been made, however, that an embryologic defect or a congenital weakness may exist which allows communication between these two spaces. It is felt that the described case and the constant findings of diaphragmatic thinness demonstrated in the stillborn dissections offer another possible etiologic factor in the production of suppurative pericarditis, namely, perforation through this congenitally weakened portion of the diaphragm, and the communication between the pericardial and peritoneal cavities. REFERENCES
I PATTON, B. M.: Human Embryology, McGraw-Hili, New York, 1968. 2 O'BRlEN, H. D.: Pericardio-peritoneal communication:
3
4
5
6
7
8
9
10
II 12 13
Description of a rare type of diaphragmatic hernia, ]. Anatomy, 74:131, 1939. BIIOADBENT, J. C., CALLAHAN, J. A., KINCAID, O. \V., AND ELLIS, F. H.: Congenital deficiency of the pericardium, Dis. Chest, 50:237, 1966. CANTIIELL, J. R., HALLEII, J. A., AND RAYITCH, ~1. ~1.: A syndrome of congenital defects involving the abdominal wall, sternum, diaphragm, pericardium and heart, Surg. Gynec. and Obstet., 107:602, 1958. LIU, D. H., CRASTNOPOL, P., AND PHILLIPS, \V.: Perforation of a gastrojejunal ulcer into the pericardium, Arch. Surgery, 94:294, 1957. MEYER, H. \V.: Pneurnopyopericardium, I. Thor. Surg., 17:62, 1948. REESE, H. E., AND STIIACENEII, C. E.: Congenital defects involving the abdominal wall, sternum, diaphragm ami pericardium: Case report and review of embryologic factors, Ann. Surgery, 163:391, 1966. HALLEH, J. A., AND CANTHELL, J. R.: Diagnosis and surgical correction of combined congenital defects of supraumbilical abdominal wall, lower sternum and diaphragm, ]. Thoracic and Cardia. Surg., 51:286, 1966. BOYLE, J. D., PEARCE, M. L., AND GUZE L. B.: Purulent pericarditis: Review of literature and report of eleven cases, Medicine, 4O:II9, 1961. GRIFFITH, G. C., AND \VALLACE, L.: The etiology of pericarditis, Dis. Chest, 23:282, 1953. MAJOlI, J. \V.: Thoracoabdominal ectopia cordis: Report of a case successfully treated by surgery, ]. Thor. Surg., 26:.'309, 1953. TEXON, M.: Purulent pericardial effusion, Amer. ]. Med., 1:577, 1946. \VADSWOHTH, G. H.: Acute suppurative pericarditis, Surg. Clinic No. America, 22:432, 1942.
Reprint requests: Dr. Devin, 2810 Arnoklson Avenue. San Diego 92122
A Useful Roentgen Sign In Dissecting Aneurysm of the Thoracic Aorta* Hadi Dizadii, M.D.,.· Carlos V. Tan, MD.,f Dorothy F. Cooney, M.D.,! and George F. O'Brien, M.D.§
A case of dissecting aneurysm of the thoracic aorta is presented. Leakage from the aorta formed an extrapleural hematoma. This hematoma appeared as a round mass with a well-delineated border on chest x-ray examination. The value of this x-ray finding in the diagnosis of dissecting thoracic aorta is emphasized.
T he
recognition of dissecting aneurysm of the aorta with its protean manifestations and its similarity to other cardiovascular emergencies, such as pulmonary embolism, acute pericarditis, and particularly myocardial infarction, make its differenti"From the Department of Internal Medicine, Cardiac Care Unit, and Department of Radiology, Mercy Hospital and Medical Center, Chicago, Illinois. • • Medical Director, Cardiac Care Unit. [Senior Resident, Department of Medicine. [Chairman, Department of Radiology. §Chairman, Department of Medicine.
DIS. CHEST, VOL. 56, NO.5, NOVEMBER 1969
DEVIN AND MERDINGER REFERENCES
2
3 4
.'5 6
7
R
9
SHAW, R. R., P AULSON, D. L., KEE, J. L. , AND LOVETT, V. F .: Pr im ary pulmonary leiomyo sarcomas, J. Thorac . Cardiocasc. Surg., 41 :430, 1961. i\"Eu~r AX:-I, R.: Le iomyosarkom der lunge, Frankfurt. Z. Path. , 52 :576, 1938. HAVARD, C . W ., AND HA:-JnURY, \ V. J.: Leiomyosarcoma of th e lung, Lancet , 2:902, 1960. RA:-'ilALL, W . S., A:-''D BLADES, B. : Primary bronchiogeni c leiom yosarcoma, Arch . Path ., 42 :543, 1946. Hrcxs, H. G .: Bronchogenic leiomyosarcoma; Ca se report with necropsy findings , Dis . Ch est, .'32:338, 1957. Hosax, A., CHnISTE:-:S E:-J, A. H., A:-:D JA~rPLls , R. W . : Primary leiomyosarcoma of the lung. Case report. Dis. Ch est, 45 :420'5, 1964. TOCKEH, A. ~1. , DEHAAN, C. , A:>''D STOFER, B. E.: Primary pulmonary leiomyosarcoma, Dis. Chest , 31 :328, 1957. GLEXX, F ., A:>:D OKr:>:AKA, A. J.: The lung tumor of a virologist. A short case report of a rare tumor and a hit of m edical history. ]. Thorne . Cardiocasc. Surt;., 0'51 :4.'5 5, 1966. YACOl.'nJ AX, II .. COXXOl.LY. J. E., x xn WYLIE, R. H. : L eiomyosarcoma of the lung, Ann. Surg. , 147:116, 195R.
Reprint requests : Chief. Supply Division, VA Hospital , Topeka, 66622
Pericardio Peritoneal CommunicationAn Additional Etiologic Factor in Purulent Pericarditis*
!"r<;URE I. Chest x-ray Hlm, March 1, HJ61. .1 CIlI below hoth costal margins. On March 4 an l'nl ar gl·r1 ca rdiac sha d ow and a large abdom inal den sit y wa s see n tin the rovntgenogrum (F ig l ). Figurr- 2 shows comp res sio n of
Joseph D edll . M.D" and Walter F. Merdinaer , M.D., F.C .C .P.
The occurrence of a case in which purulent pericarditis occurred in conjunction with a peritoneal abscess indicates that an additional etiologic factor in purulent pericarditis may be communication between the pericardial and peritoneal cavities through a congenitally weakened portion of the diaphragm.
purulent pericarditis has heen discussed often in the medical literature. Factors concerning etiology have been listed in several papers. The occurrence of a case in which communication hetween the pericardial and the abdominal cavities was dem onstrated by perforation of a peritoneal abscess into the pericardium prompted this review of literature concerning this subject and forms the hasis for this report. CASE REPORT
A two-year-old hoy was admitted March 3, 1961 to Ch ildren's Hospital, San Diego, with complaints of anorexia, an emia and th e presence of an abdominal mass. Infancy had he en complicated b y recurrent bouts of staphylococcal infections in volving skin and respiratory syst em s. Upon examination, a tender mass was palpated in th e epigastrium
"From the Department of Surrery, University Hospital, San Diego County, University 0 California (San Diego) San Diego, C alifornia.
FrGUH E 2. Lateral abdominal x-ray film. March :2, 1961.
DIS. CHEST, VOL. 56. NO.5. NOVEMBER 1969
455
PERICARDIO PERITONEAL COMMUNICATION
C+-+-AU. OC.l
HEART
c.t F J(;UIIE 3. Chest x-ray film . March 5. 1961. th e s toma ch po ste riorly h y nn ah do minal ma ss, On March 5 d yspne a, cyanosis and a tachyca rdia of 120 /lIlinllle d evel op ed rap idl y. F igll n ' 3 sho ws an inc rease in th e ca rd ia c sizo. :\ suh seq ue nt p eri card ia! tap ohtninc d ,'iO ml wh itr . purulent fluid . T he co nd itio n improved some w hat. h nt th e followin g day ma rkt·d cyanosis, neck ve in di stention n nd ('\'idl' nc(' of ucutr - card iac ta m po na d e occ ur red , Le ft a lltcrinr th ora cot om y was perform ed a nd a peri cardiaI win d ow was crea ted follo wi ng deco mpression of a marke d ly d iskn(\ed peri cardium . As d eco mpres sion cn ntin ue r], sim nltnnoon s resolution of th e a bdomi nal mass occu rr ed . Ab dominal exp loration rr-veulrxl m ark ed hcp ntom c unly. a nd an abscess Ir in g uhovr- tlu- ldt lolx- of th e liver and ante rio r to th e stomach . Th is wa s d ra ined h )' means of slimp tuhe x, TI ll' organ ism was id" n lif1('d as Stap l, !/lncncc lIs aurcu s, coa gn lase posit in '. Fo llo wi n g a sto rm y postop e rat ive co ur se . tlu - eh il,1 improved anti w as dis ch ar g(·(1. Fi gHT(' 4 is Ill(' clu -st filill tak en june 19. HJIH . DlSCUSSIO~
A review of the embrvologic dev elopment of the
FI Gt:nE 4 . Ch est x-ray film.l nlle 19. 1961.
DIS. CHEST, VOL. 56. NO.5, NOVEMBER 1969
r.i
FIt: l'II ~:
Pallen).
:>. J),· \'(·lupn wnl o f sepu u u inl rnnsv" rsiull (a ft,· r
diaphragm and pericardium shows that the primitive coelom is divided hy three sets of partitions, Th e unpaired septum transversurn arises from a cranially located portion of mesoderm which und ergoes reversal of position. coming to fonn a transverse partition between the pleural and peritoneal cavities ( Fig 5 ). Thi s septum is imperfect as paired pleural canals course dorsally ab ove the septum on each side conn ecting the pleural and abdominal portions of the ~eneral coelom. The pleuro-peri -
FIGURE 6. Newborn diaphragm.
456
DIZADJI ET AL
toneal membranes supplement the septum transversum and complete the isolation of true pleural, pericardiaI and peritoneal cavities. I Defects in the diaphragm may occur, leading to herniation of abdominal contents. These are commonly at the site of the left pleuro-peritoneal membrane, the foramen of Bochdalek and at the foramen of Morgagni. To postulate the formation of a communication between the pericardium and the peritoneal cavity would necessitate this communication to arise from the unpaired portion of mesoderm forming the septum transversum, Such a communication has been reported only once in the world literature by O'Brien in 1939, reporting on an autopsy case of a 63-year-old Russian man," Numerous other reports have recorded defects in the diaphragmatic pericardium. These have all occurred in the anterior portion of the pericardium and have occurred in association with multiple anomalies, including defects of the upper abdominal wall, sternum and heart. H With knowledge of the embryologic peculiarities involving the peritoneal pericardial communication, several stillborn infants have been examined and the diaphragmatic portion of the pericardium and the diaphragm were closely examined. A constant feature of these dissections was the presence of a markedly thinned-out area in the mid-portion of the diaphragm. Such an area is demonstrated in Fig 6. CONCLUSION
Numerous authors have reviewed suppurative pericarditis and have included as etiologic factors septicemia, tuberculosis, bronchopneumonia, empyema, carcinoma and even perforation of a gastrojejunal ulcer into the pericardium.v'!" Other reports have indicated the associated presence of a peritoneal abscess. Pericarditis or pleural effusion in these instances is believed secondary to perforation of the abscess through the diaphragm. No mention has been made, however, that an embryologic defect or a congenital weakness may exist which allows communication between these two spaces. It is felt that the described case and the constant findings of diaphragmatic thinness demonstrated in the stillborn dissections offer another possible etiologic factor in the production of suppurative pericarditis, namely, perforation through this congenitally weakened portion of the diaphragm, and the communication between the pericardial and peritoneal cavities. REFERENCES
I PATTON, B. M.: Human Embryology, McGraw-Hili, New York, 1968. 2 O'BRlEN, H. D.: Pericardio-peritoneal communication:
3
4
5
6
7
8
9
10
II 12 13
Description of a rare type of diaphragmatic hernia, ]. Anatomy, 74:131, 1939. BIIOADBENT, J. C., CALLAHAN, J. A., KINCAID, O. \V., AND ELLIS, F. H.: Congenital deficiency of the pericardium, Dis. Chest, 50:237, 1966. CANTIIELL, J. R., HALLEII, J. A., AND RAYITCH, ~1. ~1.: A syndrome of congenital defects involving the abdominal wall, sternum, diaphragm, pericardium and heart, Surg. Gynec. and Obstet., 107:602, 1958. LIU, D. H., CRASTNOPOL, P., AND PHILLIPS, \V.: Perforation of a gastrojejunal ulcer into the pericardium, Arch. Surgery, 94:294, 1957. MEYER, H. \V.: Pneurnopyopericardium, I. Thor. Surg., 17:62, 1948. REESE, H. E., AND STIIACENEII, C. E.: Congenital defects involving the abdominal wall, sternum, diaphragm ami pericardium: Case report and review of embryologic factors, Ann. Surgery, 163:391, 1966. HALLEH, J. A., AND CANTHELL, J. R.: Diagnosis and surgical correction of combined congenital defects of supraumbilical abdominal wall, lower sternum and diaphragm, ]. Thoracic and Cardia. Surg., 51:286, 1966. BOYLE, J. D., PEARCE, M. L., AND GUZE L. B.: Purulent pericarditis: Review of literature and report of eleven cases, Medicine, 4O:II9, 1961. GRIFFITH, G. C., AND \VALLACE, L.: The etiology of pericarditis, Dis. Chest, 23:282, 1953. MAJOlI, J. \V.: Thoracoabdominal ectopia cordis: Report of a case successfully treated by surgery, ]. Thor. Surg., 26:.'309, 1953. TEXON, M.: Purulent pericardial effusion, Amer. ]. Med., 1:577, 1946. \VADSWOHTH, G. H.: Acute suppurative pericarditis, Surg. Clinic No. America, 22:432, 1942.
Reprint requests: Dr. Devin, 2810 Arnoklson Avenue. San Diego 92122
A Useful Roentgen Sign In Dissecting Aneurysm of the Thoracic Aorta* Hadi Dizadii, M.D.,.· Carlos V. Tan, MD.,f Dorothy F. Cooney, M.D.,! and George F. O'Brien, M.D.§
A case of dissecting aneurysm of the thoracic aorta is presented. Leakage from the aorta formed an extrapleural hematoma. This hematoma appeared as a round mass with a well-delineated border on chest x-ray examination. The value of this x-ray finding in the diagnosis of dissecting thoracic aorta is emphasized.
T he
recognition of dissecting aneurysm of the aorta with its protean manifestations and its similarity to other cardiovascular emergencies, such as pulmonary embolism, acute pericarditis, and particularly myocardial infarction, make its differenti"From the Department of Internal Medicine, Cardiac Care Unit, and Department of Radiology, Mercy Hospital and Medical Center, Chicago, Illinois. • • Medical Director, Cardiac Care Unit. [Senior Resident, Department of Medicine. [Chairman, Department of Radiology. §Chairman, Department of Medicine.
DIS. CHEST, VOL. 56, NO.5, NOVEMBER 1969