A 24-year-old man presented to the emergency department with dyspnea and persistent cough. In physical exam, no abnormality was found. His past medical history was normal. Such an episode occasionally presented in the past year. There was no recent weight loss, cough, sputum production, exposure to tuberculosis, joint pain, or rash. The electrocardiogram (ECG) was normal.
Chest X-ray showed a large opacity obscuring the right heart border (Figure 1). His trans-thoracic echocardiogram showed an echo-lucent space next to the right atrium at the right cardiophrenic angle. His echocardiogram was normal, and no pericardial effusion was found. The apical four-chamber view of the transthoracic echocardiogram showed an echolucent space next to the right atrium at the right cardiophrenic angle, consistent with a pericardial cyst. The right and left ventricular chamber size and function were normal, and there was no valvular heart disease
Then computed tomography (CT) was recommended. CT revealed no pleural effusions, and a large fluid collection at the right pericardial border (Figure 2).
Extensive work-up for infectious and inflammatory causes, including blood cultures, viral antibodies, sputum acid fast bacilli's (AFB), PPD testing, and collagen vascular disease markers was negative.
The patient was referred to a cardiac surgeon. After midsternotomy, the pericardium was opened. No fluid or pathologic finding was seen in the pericardium. On the right side and outside the pericardium, a huge pericardial cyst measuring approximately 13 x 8 x 5 cm in diameter was found and totally excised (Figures 3 and 4).
After 5 days, the patient was discharged uneventfully. Pathologic report confirmed the diagnosis. The patient remains symptom-free in the 12 month follow-up visit.