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| CASE REPORT |
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| Year : 2017 | Volume
: 3
| Issue : 3 | Page : 176-177 |
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Free floating stone in the pericardial cavity (Pericardiolith): Rare finding
Sudheer Arava1, Harisha Kusuma2, Palleti Rajashekhar3, Amol Bhoje3, Ruma Ray1
1 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
3 Department of Cardiothoracic Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| Date of Web Publication | 1-Feb-2018 |
Correspondence Address:
Dr. Sudheer Arava
Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpcs.jpcs_51_17
How to cite this article:
Arava S, Kusuma H, Rajashekhar P, Bhoje A, Ray R. Free floating stone in the pericardial cavity (Pericardiolith): Rare finding. J Pract Cardiovasc Sci 2017;3:176-7 |
How to cite this URL:
Arava S, Kusuma H, Rajashekhar P, Bhoje A, Ray R. Free floating stone in the pericardial cavity (Pericardiolith): Rare finding. J Pract Cardiovasc Sci [serial online] 2017 [cited 2023 Jun 4];3:176-7. Available from: https://www.j-pcs.org/text.asp?2017/3/3/176/224486 |
Loose body is defined as a free-floating bone, cartilage or a foreign object commonly encountered in the joint space and rarely reported in the pleural cavity as pleural stone or thoracolith.[1] To the best of our knowledge, this is the first case of pericardial loose body (Pericardiolith) in the literature.
A 60-year-old male who was a known case of rheumatic heart disease (RHD) since 40 years presented with a history of cerebrovascular accident, dyspnea on exertion, bilateral pedal edema, and right hemiparesis. History revealed percutaneous transvenous mitral commisurotomy done for severe mitral stenosis 10 years back. He had a history of the left above knee amputation for embolic gangrene. Examination revealed atrial fibrillation, raised jugular venous pressure, paroxysmal nocturnal dyspnea, and syncope. Respiratory system revealed bilateral basal crepitations. Electrocardiogram showed left ventricular hypertrophy chest X-ray showed mild cardiomegaly with a radiopaque shadow corresponding to the apex of the heart [Figure 1]a. Echocardiography revealed severe mitral stenosis with mitral valve area of 0.6–0.8 cm 2, moderate aortic stenosis with aortic regurgitation. There was a large free-floating thrombus measuring 26 mm × 24 mm present in the left atrium. Tricuspid valve was normal with trivial tricuspid regurgitation. Biventricular function was normal. Coronary angiography revealed normal coronaries. With these findings final clinical diagnosis of RHD with severe mitral stenosis, moderate aortic stenosis, and trivial aortic regurgitation was made. The patient was planned for open-heart surgery. Preoperative radiology and intraoperative procedure showed a thickened and calcified mitral and aortic valves with a free globular stone in the pericardial cavity. Double valve replacement surgery with left atrial and bilateral femoral artery embolectomy was done. Valvectomy, clot, and calcified loose body were sent for histopathological analysis. | Figure 1: (a) Chest X-ray: Free floating small nodule near the apex of the heart (arrow). (b) Gross: White calcific stone with smooth surface. (c) Microscopy: Peripheral calcification with central necrotic adipose tissue (arrow).
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Macroscopically, the loose body was single, globular with a white smooth surface. It was measuring 1 cm × 0.8 cm × 0.4 cm in maximum dimensions with a stone-like consistency [Figure 1]b. Microscopic examination of the stone after decalcification showed concentric layer of calcification with a central area showing necrotic fat [Figure 1]c. Histopathological examination of the mitral valve revealed features of postinflammatory/postrheumatic changes characterized by dense fibrosis with dystrophic calcification without any significant chronic inflammation. Definitive Aschoff nodule was not identified in the sections examined. Left atrial and femoral artery embolectomy specimen showed histomorphology of aseptic fresh fibrin-rich clot.
Dias et al.[2] published the first case report of pleural loose body in 1968, after that only few case reports have been published in the literature. Till now, there has not been a single case report of loose body in the pericardial cavity reported in the English literature. In most of the cases, patients are asymptomatic, and the loose bodies are detected incidentally during surgery or routine radiological examinations done for some other reasons. On radiology, they look like small well-circumscribed calcific nodule of varying sizes ranging from 0.4 to 5 cm.[3] Exact etiologies for the formation of these stones are unclear, but it is thought to be multifactorial including ischemia, repetitive trauma, and abnormal calcification. Some explanations proposed in the literature are evidence of fat necrosis leading to calcification and separation to form a loose body in the pleural cavity.[4] As our case showed central area of fat necrosis surrounded by layers of dystrophic calcification, it reveals that the fat necrosis theory leading to calcification and formation of loose body is the appropriate pathophysiology that can be explained in the development of the freely floating stone in this case. The cause of fat necrosis can be traced back to the RHD history since 40 years in this patient with chronic pericarditis leading to fat necrosis. Commonly in majority of the cases, chronic pericarditis show the presence of amorphous or plaque-like areas of dystrophic calcification, but this is the only single case which showed loose stone in the pericardial cavity. Literature says the presence of loose body in the thoracic cavity as “Thoracolith;” hence, we are giving the nomenclature as “Pericarditis” for this case. Although they are extremely rare, knowledge regarding this entity is important. Usually, they are small and incidental findings, treatment is not required unless there are clear associated symptoms.
Acknowledgment
All authors are contributed equally in the diagnosis and preparation of the manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Rawstorne E, Muzaffar J, Hawari M, Naidu P, Steyn R. Multiple thoracolithiasis: An incidental finding. J Surg Case Rep 2012;2012:1.  [ PUBMED] |
| 2. | Dias AR, Zerbini EJ, Curi N. Pleural stone. A case report. J Thorac Cardiovasc Surg 1968;56:120-2. [ PUBMED] |
| 3. | Spitz WU, Taff ML. Intrapleural golf ball size loose body. An incidental finding at autopsy. Am J Forensic Med Pathol 1985;6:329-31. [ PUBMED] |
| 4. | Strzelczyk J, Holloway BJ, Pernicano PG, Kelly AM. Rolling stones in the pleural space: Thoracoliths on CT, and a review of the literature. Clin Radiol 2009;64:100-4. [ PUBMED] |
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