PICTORIAL ESSAY

A 45-year-old Malagasy man, with a 2-month medical history of chronic 
pericarditis, presented to the Department of Cardiology at Joseph Raseta 
Hospital with cardiac tamponade. Pericardiocentesis was performed, 
with improvement in the patient’s clinical condition, following aspira-
tion of 400 cc of serofibrinous fluid. The control chest X-ray revealed 
a hydropneumopericardium (Figs 1a and 1b). Following evaluation of 
the fluid, tuberculosis treatment was started with an adjunctive cor-
ticosteroid régimen and resultant complete resolution of all cardiac 
symptoms.

The diagnosis of hydropneumopericardium requires the application 
of Shackelford criteria which include (i) high-pitched tympanic percus-
sion note, (ii) loud metallic splashing sound synchronous with heart 
sounds, and (iii) characteristic chest X-ray with an air-fluid level in the 
pericardial cavity.1

Traumatic origins of hydropneumopericardium are more common 
than non-traumatic causes. Non-traumatic causes of hydropneumope-
ricardium include asthma, gastro-pericardic fistula complicating gastric 
pathology, and infectious disease from illnesses such as pericarditis and 
pneumonia. Traumatic causes are many and varied, including chest trau-
ma (11%) and iatrogenic causes (74%), particularly those arising after 
mechanical ventilation, cardiac surgery, and pace-maker implantation.2 
Pericardiocentesis is the cornerstone of the management of cardiac tam-
ponade. Kabukcu has performed 50 such procedures safely.3 There are 
few reports of pneumopericardium linked to pericardic drainage.4

Cardiac tamponade is encountered in 37.7% of pneumopericardium 
cases.2 Although its occurrence is not dependent upon the quantity of air 
in the pericardic cavity, spontaneous remission has been documented in 
the case of a small pneumopericardium.5

1. Shackelford RT. Hydropneumopericardium. JAMA 1931; 96: 187-191.
2.  Wu M, He X, Yang G. Spontaneous tension hydropneumopericardium complicating serofibrinous pericar-

ditis. Eur J Cardiothorac Surg 2006; 29: 422-424.
3.  Kabukcu M, Demircioglu F, Yanik E, Basarici I, Ersel F. Pericardial tamponade and large pericardial effu-

sion: causal and efficacy of percutaneous catheter drainage in 50 patients. Heart Inst J 2004; 31: 398-403.
4. Gan H, Simpson JM. Pneumopericardium presenting as reduced ECG voltages. Heart 2005; 91: 298.
5.  Levin S, Maldonado I, Rehm C, Ross S, Weiss R. Cardiac tamponade without pericardial effusion after 

blunt chest trauma. Am Heart J 1996; 131: 198-200.

Large uncomplicated hydropneumopericardium

R A Rakotoarivelo, MD
S H Razafimahefa, MD

P Ramanalimanana, MD
D Ranoharison, MD
A D Johnson, MD

S Rakotoarimanana, PhD

Department of Cardiology, Joseph Raseta Hospital, University Hospital 
Center of Antananarivo, Antananarivo, Madagascar

Fig. 1a and b. Chest X-ray after pericardiocentesis. Hydropneumopericardium showing air/fluid level: frontal view (a) and side view (b).

19         SA JOURNAL OF RADIOLOGY • March 2010

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