Extract

A 53-year-old man presented to the emergency department due to acute onset of chest pain during eating breakfast. Emergent cardiac troponin was negative and electrocardiogram showed low voltage in limb lead with diffuse concave ST-segment elevation and PR-segment depression, which was suggestive of pericarditis (Panel A). The patient gradually developed shortness of breath and was admitted to the hospital after large pneumopericardium was found on chest computed tomography (PanelsB and C). Five weeks earlier, the patient started to receive high-dose radiotherapy with concurrent chemotherapy for recurrent lung cancer and developed dysphagia 2 weeks after initiation of radiochemotherapy. Uppergastroenterography (Panel D, arrow) and oesophagoscopy (Panel E, arrow) were performed, which confirmed an oesophageal fistula 3.0 cm in diameter and 36 cm from the incisor.

We performed emergent pericardiocentesis to relieve cardiac tamponade and drained 150 ml of gas and 50 mL of nepheloid fluid. An immediate surgical referral was made which was refused by the patient. Therefore, a covered stent was placed under the endoscopic guidance. A feeding tube was placed to ensure nutrition, and continuous pericardium drainage was performed. Two weeks later, pneumopericaridum disappeared and the fistula became smaller.

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