pneumopericardium is defined as the presence of air - fluid level in the pericardial sac and has been reported to result from a spontaneous or iatrogenic cause of underlying disease.1 ) it is a rare condition but is important in the differential diagnosis of chest pain . posteroanterior chest radiographs typically reveal air - fluid level and a radiolucency of air surrounding the cardiac boarder is outlined by a fine line representing the pericardial sac . although severe complications occur in some patients , the iatrogenic pneumopericardium is self - limiting and requires no specific therapy.2 ) we discuss a case of iatrogenic pneumopericardium in a young man who underwent pericardiocentesis due to tuberculous pericardial effusion . a 20-year - old man was referred to the hospital with extensive pericardial effusion on a computed tomography . the patient had a history of pulmonary tuberculosis for 2 years and had taken anti - tuberculosis medication for the past 8 months . physical examination showed stable vital signs : blood pressure , 131/65 mmhg ; pulse rate , 92 bpm ; respiratory rate , 26 per minute ; body temperature , 36.5. posteroanterior chest radiographs showed cardiomegaly without any lung lesion ( fig . 1 ) . an emergent echocardiogram showed a large circumferential pericardial effusion and diastolic right atrium collapse without respiratory variation of the mitral inflow . the left ventricular ejection fraction was estimated to be 60% . a 7fr arrowgard blue catheter ( arrow international inc , bernville , pa , usa ) was used for subxiphoid pericardiocentesis . over 1,000 ml of serous fluid was drained from the pericardial sac over the following 12 hours . the pericardial fluid was a lymphocyte dominant exudate , containing protein 6.5 g / dl , albumin 3.6 g / dl , lactate dehydrogenase 466 u / l and white blood cell 7,200 cells/l ( lymphocyte 84% ) . polymerase chain reaction for mycobacterium tuberculosis deoxyribonucleic acid was negative with pericardial fluid and adenosine deaminase in pericardial effusion was 96 iu / l ( normal , 5 to 23 iu / l).3 ) on day 5 after the pericardiocentesis the patient developed a pleuritic chest pain . his blood pressure was 110/70 mmhg , heart rate was 72 bpm , and respiratory rate was 20 per minute . follow up chest radiographs showed a new lucent outline around the heart with a clear lung , representing the existence of air - fluid level in the pericardial space ( fig . 3 ) . echocardiography revealed scanty pericardial effusion , a bright echogenic spot swirling in the pericardial cavity and an absent tamponade ( fig . the diagnosis of pneumopericardium can be made by conventional chest radiographs , ct , or echocardiography.5 ) in posteroanterior chest radiographs , a continuous thin radiolucent rim of air and air - fluid level follows the cardiac silhouette and is outlined by a fine line representing the pericardial sac.2 ) pericardiocentesis with extended catheter drainage is a safe treatment for managing clinically significant pericardial effusions and can be performed effectively under local anesthesia.6 ) the subxiphoid window should be the standard initial procedure in most patients requiring drainage for effusive pericardial disease . it is less morbid than the transthoracic approach and allows a shorter hospital stay.7 ) for our patient we hypothesized that pneumopericardium was induced by chance due to forced coughing during drainage after pericardiocentesis . in tension pneumopericardium , rapid fluid resuscitation and emergent echo - guided pericardiocentesis , followed by pericardial drainage , should be performed . if the hemodynamic condition is stable , the underlying condition should be treated and the patient should be monitored closely.2 ) the patient was in a tolerable state , so we treated him conservatively and removed catheter drainage . the current case showed that pneumopericardium is a rare complication of pericardiocentesis , which occurs as a result of a leaky drainage system or direct pleura - pericardial communication .
pneumopericardium is a rare complication of pericardiocentesis , occurring either as a result of direct pleuro - pericardial communication or a leaky drainage system . 
 air - fluid level surrounding the heart shadow within the pericardium on a chest x - ray is an early observation at diagnosis 
 . this clinical measurement and process is variable , depending on the hemodynamic status of the patient . 
 the development of a cardiac tamponade is a serious complication , necessitating prompt recognition and treatment . 
 we recently observed a case of pneumopericardium after a therapeutic pericardiocentesis in a 20-year - old man with tuberculous pericardial effusion .