[Purulent pericarditis as an initial manifestation of esophageal carcinoma]

A 71-year old heavy smoker was admitted because of chest pain unrelated to physical activity, radiating into the left arm and neck as well as exertional dyspnoea and dizziness. Physical examination was unremarkable except for mild venous congestion over the upper part of the body. Myocardial infarction was excluded. A haemodynamically significant pericardial effusion developed a few days later and required emergency pericardiocentesis.

Laboratory tests indicated marked inflammatory disease. Echocardiography demonstrated the pericardial effusion. Needle aspiration revealed coagulase-negative staphylococcus and plant cells. Chest X-ray showed a pneumopericardium. Computed thoracic tomography suggested malignant tumour of the oesophagus with spread to the surrounding lymph nodes and pericardial fistula. Proximal endoscopy showed a highly malignant looking ulcer, 30 cm in diameter, in the anterior wall of the oesophagus with a central fistula. The endoscopic biopsy indicated a poorly differentiated non-cornified squamous cell carcinoma.

An uncovered self-expanding metal stent was placed into the fistula, whereupon the perimyocarditis quickly healed. When the patient was discharged he was able to take food by mouth and the signs of inflammation subsided. He died at home 6 weeks later.

An oesophageal carcinoma with fistula should be included in the differential diagnosis of purulent pericardial effusion even in the absence of dysphagia. Implantation of a self-expanding metal stent into the fistula is the treatment of choice for palliation.