Epipericardial fat necrosis: a rare case of chest pain and key learning points

Epipericardial fat necrosis is a rare, self-limiting cause of acute pleuritic chest pain that is frequently misdiagnosed due to its clinical similarities with more serious cardiopulmonary conditions. Early recognition of its characteristic imaging features is essential to avoid unnecessary diagnostic procedures and treatments.

A 27-year-old male presented with progressive retrosternal chest pain lasting 24 hours. The initial evaluation was unremarkable except for subtle blunting of the cardiophrenic angles. His symptoms improved after receiving an anti-inflammatory injection but recurred several hours later. Repeated investigations remained normal. Chest computed tomography revealed an ovoid fat-density lesion with a soft-tissue rim and surrounding inflammatory changes in the pericardial region, consistent with epipericardial fat necrosis. A retrospective review of the initial chest radiograph identified subtle but supportive findings. Conservative treatment with oral anti-inflammatory medication led to the complete resolution of symptoms within one week.

Epipericardial fat necrosis is a benign and under-recognized condition that can mimic life-threatening causes of chest pain, such as pulmonary embolism, acute coronary syndrome, or pericarditis. Computed tomography is the preferred imaging modality for diagnosis. Treatment is conservative and typically results in full recovery.

Epipericardial fat necrosis should be considered in the differential diagnosis of acute chest pain when initial evaluations are inconclusive. Increased clinical awareness and accurate interpretation of imaging findings are crucial for prompt diagnosis and the avoidance of unnecessary interventions.