key: cord-0903216-sm5e6nw6 authors: van den Heuvel, Frederik M A; Dimitriu-Leen, Aukelien C; Habets, Jesse; Nijveldt, Robin title: Case report: epipericardial fat necrosis—a rare cause of chest pain date: 2021-12-31 journal: Eur Heart J Case Rep DOI: 10.1093/ehjcr/ytab529 sha: c5a85eef92ef7822390ce4de69d2d5a17a308336 doc_id: 903216 cord_uid: sm5e6nw6 BACKGROUND: Epipericardial fat necrosis (EFN) is a rare cause of chest pain, which is often unrecognized. CASE SUMMARY: A 58-year-old man previously known with a transient ischaemic attack presented with a sharp, substernal chest pain. Pulmonary embolism was ruled out by computed tomography (CT) angiography. However, CT angiography revealed an inhomogeneous epipericardial mass. On cardiovascular magnetic resonance imaging, the mass had an inhomogeneous signal intensity without infiltration of surrounding tissue. Late gadolinium enhancement imaging showed subtle hyperenhancement. Tissue characterization by means of parametric mapping revealed very low native T1 relaxation times and increased T2 relaxation times. In conclusion, the epipericardial mass showed fibrofatty inflammatory markers, suggestive of EFN. The chest pain resolved spontaneously. Follow-up CT 3 months later showed a marked regression of the mass which confirmed the diagnosis EFN. DISCUSSION: Epipericardial fat necrosis is a benign and self-limiting inflammatory cause of chest pain, which can be diagnosed with multi-modality imaging and must not be overlooked in the differential diagnosis of patients with acute pleuritic chest pain. Chest pain is a frequent cause of emergency department admission and has a wide differential diagnosis ranging from benign to lifethreatening diseases. One of those benign diseases is epipericardial fat necrosis (EFN), which is a rare cause of chest pain and is often not recognized. 1 In this case report, we present a case of EFN diagnosed with multi-modality imaging. • Epipericardial fat necrosis is a rare and benign cause of chest pain. • Epipericardial fat necrosis can be diagnosed with cardiovascular magnetic resonance imaging using parametric mapping. * A 58-year-old man, presented to the emergency department with 2 days of sharp, substernal chest pain which worsened during inspiration. The patient was previously known with hypertension and a transient ischaemic attack and was on clopidogrel, atorvastatin, and valsartan at admission. He presented with a temperature of 36.2 C, a blood pressure of 131/78 mmHg, a regular pulse of 98 beats per minute, and a saturation of 98% on ambient air. Clinical examination was unremarkable without pericardial or pleural friction rub. The electrocardiogram was normal without repolarization disorders or signs of pericarditis. Laboratory examination showed normal leucocyte count, elevated C-reactive protein of 44 mg/L (reference value < 10 mg/L), and mildly elevated high-sensitivity troponin T of 20 ng/L (reference value < 14 ng/L) with a rise to 30 ng/L. Polymerase chain reaction of a nasopharyngeal sample was negative for coronavirus. Our differential diagnosis included (myo)pericarditis, non-ST elevation myocardial infarction, pulmonary embolism, pleuritis, and acute aortic syndrome. The patient was hospitalized for further analysis. Obstructive coronary artery disease was ruled out by invasive coronary angiography. A contrast-enhanced computed tomography (CT) angiography showed no pulmonary embolism, aortic dissection, pericardial effusion, or intrapulmonary abnormalities, but revealed an inhomogeneous epipericardial mass ( Figure 1 ). The chest pain resolved spontaneously the following day and the patient was discharged without any treatment. Cardiovascular magnetic resonance imaging (CMR) was performed 5 days later using a 1.5 Tesla clinical magnetic resonance imaging (MRI) scanner, which showed normal anatomy and myocardial function. On cine MRI, the epipericardial mass had an inhomogeneous signal intensity without infiltration of surrounding tissue and absence of pericardial effusion (Video 1). Further tissue characterization of the mass by means of parametric mapping showed very low native T1 relaxation times (283 ms) ( Figure 2A ) consistent with fat. T2 relaxation times (100 ms) were elevated ( Figure 2B ) and T2weighted oedema imaging ( Figure 2C ) revealed hyperintense areas of the mass both consistent with oedema. Late gadolinium enhancement imaging demonstrated hypo-enhanced areas surrounded by areas of hyperenhancement ( Figure 2D ). In conclusion, the mass showed fibrofatty inflammatory markers, suggestive of EFN. Followup CT 3 months after admission showed a marked regression of the epipericardial mass which confirm the diagnosis EFN ( Figure 3) . The patient remained asymptomatic and no further follow-up was indicated. Epipericardial fat necrosis is a rare and underdiagnosed cause of chest pain. 1, 2 The incidence of EFN is about 2.2% among patients who underwent chest CT for chest pain on the emergency department. 3 Chest pain is most often classified as acute pleuritic chest pain 1 which can mimic other acute conditions such as acute myocardial infarction, pericarditis, pulmonary embolism, and pleuritis. Clinical examination is often unremarkable, without abnormalities on electrocardiogram and no typical rise and fall in troponin. 1 Epipericardial fat necrosis can be diagnosed using contrast-enhanced CT or CMR using parametric Video 1 Cardiovascular magnetic resonance imaging. Cardiovascular magnetic resonance imaging cine imaging shows a substernal epipericardial mass with inhomogeneous signal intensity and without infiltration of surrounding tissue nor pericardial effusion. Epipericardial fat necrosis is a benign and self-limiting inflammatory process, 2 but could be treated with non-steroidal anti-inflammatory medication. 1, 4 There are currently no clear recommendations in the literature or guidelines on when to start non-steroidal anti-inflammatory medication. As recommended in the literature, 1 follow-up CT after 4-8 weeks is recommended to confirm regression of the mass and exclude malignancy. In conclusion, EFN is a rare cause of chest pain and must not be overlooked in the differential diagnosis of patients with acute pleuritic chest pain. Supplementary material is available at European Heart Journal -Case Reports online. Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data. The authors confirm that written informed consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Epipericardial fat necrosis: an underdiagnosed condition Mediastinal (epipericardial) fat necrosis: an overlooked and little known cause of acute chest pain mimicking acute coronary syndrome Epipericardial fat necrosis: who should be a candidate? Epicardial fat necrosis: an uncommon etiology of chest pain Funding: None declared.