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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
Tex Heart Inst J. 2007; 34(3): 379–382.
PMCID: PMC1995052

Chylopericardium Presenting as Cardiac Tamponade Secondary to an Anterior Mediastinal Cystic Teratoma


Cardiac tamponade, the accumulation of fluid in the pericardial space, leads to impaired venous return, loss of left ventricular preload, and hemodynamic collapse. The many causes of tamponade include malignancy, infection, inflammation, connective tissue disorders, and uremia.

Herein, we report the case of a young woman who presented with syncope. She was found to have cardiac tamponade secondary to a chylous pericardial effusion that was due to a mature and benign anterior mediastinal cystic teratoma. Numerous reports have described pericardial effusions secondary to an anterior mediastinal cystic teratoma; however, to our knowledge, this is the 1st case of a teratoma causing chylopericardium that presented as tamponade.

Key words: Cardiac tamponade/etiology/physio-pathology, chyle, chylo-thorax/etiology/radiography/surgery, drainage, echocardiography, mediastinal neoplasms/complications/pathology, pericardial effusion/diagnosis/etiology/pathology/radiography/surgery, photomicrography, rare diseases/diagnosis, teratoma/complications/pathology/surgery

Cardiac tamponade is a well-known clinical entity that can be rapidly fatal if it is not treated promptly. The condition is caused by the accumulation of fluid in the pericardial space, which leads to impaired venous return, loss of left ventricular preload, and hemodynamic collapse. The pericardial effusion can be a sequela of malignancy, inflammation, infection, connective tissue disorders, uremia, pleural effusion with extension, or trauma, or it can be idiopathic.1 A rarer cause of tamponade is the accumulation of chyle. Chylopericardium can result from inflammatory disorders, such as pancreatitis; however, most cases of chylopericardium can ultimately be attributed to microperforations in the thoracic duct.2–7 We present the case of a young woman who experienced cardiac tamponade from chylopericardium that was secondary to an anterior mediastinal mature cystic teratoma.

Case Summary

In August 2003, an 18-year-old woman with no personal or family history of cardiac disorders presented at our emergency department after an episode of syncope. She had spent the day at an amusement park where the ambient temperature was high, and she reportedly had not consumed much liquid all day. While standing in line, she had felt dizzy and passed out, and then rapidly regained consciousness and awareness of her surroundings. She had not experienced chest pain, dyspnea on exertion, shortness of breath, nausea, or palpitations. There was no loss of bowel or bladder function.

She was rehydrated with intravenous fluids and sent home. Over the next few weeks, she developed a fever of 102 °F as measured orally, and she began to experience nonexertional chest pain and shortness of breath. Her pediatrician diagnosed infectious mononucleosis. She experienced 3 more syncopal episodes over the next 2 to 3 weeks, along with chest pain and shortness of breath.

She was re-evaluated and referred to a cardiologist. Physical examination revealed pulsus paradoxus and jugular venous distention without pericardial friction rub or murmurs. Electrocardiography showed low-voltage complexes and nonspecific T-wave changes in leads III and aVF (Fig. 1). An echocardiogram revealed extensive anterior and posterior pericardial effusion, with evidence of cardiac tamponade.

figure 22FF1
Fig. 1 Electrocardiogram on presentation shows low-voltage complexes and nonspecific T-wave changes in leads III and aVF.

The patient was immediately sent to the hospital for pericardiocentesis. Approximately 900 mL of thick yellow fluid was drained from the pericardium and analyzed; it contained 503 mg/dL total cholesterol and 328 mg/dL triglycerides, consistent with chylous pericardial fluid. Gram-stain, bacterial, echinococcal, and viral cultures were negative. A pericardial drain was placed. Repeat echocardiography confirmed reaccumulation of the effusion. A computed tomograph-ic scan of the chest revealed a 10.3 × 8.7 × 11-cm cys-tic mass in the anterior mediastinum, extending into the right hemithorax with pericardial effusion (Fig. 2). Surgical resection revealed a mass (16 × 11 × 7 cm) that consisted of skin (Fig. 3), bronchial tissue, pancre-atic tissue (Fig. 4), smooth muscle (Fig. 5), fat, and brain tissue. The mass appeared not to have ruptured, but there was a communication with the pericardium. Histopathologic analysis confirmed that the mass was a mature cystic teratoma. Lymph node biopsies were negative for metastasis. The patient did well and was discharged from the hospital on the 7th postoperative day without complications.

figure 22FF5
Fig. 5 Photomicrograph shows smooth muscle tissue in the mesoderm of the teratoma (H & E, orig. ×200).
figure 22FF4
Fig. 4 Photomicrograph shows pancreatic tissue in the endoderm of the teratoma (H & E, orig. ×200).
figure 22FF3
Fig. 3 Photomicrograph shows skin tissue with skin appendages in the ectoderm of an anterior, mediastinal, mature, benign cystic teratoma (H & E, orig. ×100).
figure 22FF2
Fig. 2 Computed tomographic scans of the chest. A) An anterior mediastinal mass (10.3 × 8.7 × 11 cm) is seen to have a large central septation. The left-sided portion of the septated mass extends into the left hemithorax, encasing the ...


Chylopericardium is a relatively rare clinical entity that constitutes only a fraction of cardiac tamponade cases. Inflammatory disorders and malignancies are the usual causes of chylous pericardial effusions; in such cases, there is demonstrable communication between the thoracic duct and the pericardium that may or may not be visible on lymphangiography.8–10 Disruptions in the integrity of the thoracic duct can occur consequent to trauma (including surgery and catheter-related sequelae), thereby creating a conduit for chyle to pass into the pericardial and pleural spaces.11,12 Numerous reports describe chylothorax and chylous pericardial effusions that have resulted from primary pulmonary neoplasms such as lymphangioleiomyomatosis and signet-ring cell carcinoma, and from extrapulmonary malignancies such as leukemia.13–16

Anterior mediastinal teratomas are known to cause both pleural and pericardial effusions, and there are documented cases of cardiac tamponade due to local invasion and rupture into the pericardial space.17–21 When these tumors rupture, however, analysis frequently reveals exudative fluid that is hemorrhagic but not chylous. In a case similar to ours, a young woman had turbid fluid drained from the pericardium; however, on analysis, that fluid was not chyle.22 Although multiple manifestations of cardiopulmonary disorders secondary to mature cystic teratoma have been reported,23–29 there are, to our knowledge, no other reported cases of cardiac tamponade from chylopericardium that originated from an anterior mediastinal mature, benign cystic teratoma.


Address for reprints: David J. Revere, MD, Department of Medicine, Long Island Jewish Medical Center, 270–05 76th Avenue, New Hyde Park, NY 11040. E-mail: moc.oohay@dmrd;f5000x#&rd


1. Yokusoglu M, Savasoz BS, Baysan O, Erinc K, Gunay C, Isik E. Primary chylopericardium. Thorac Cardiovasc Surg 2005; 53:386–8. [PubMed]
2. Arendt T, Bastian A, Lins M, Klause N, Schmidt WE, Folsch UR. Chylous cardiac tamponade in acute pancreatitis. Dig Dis Sci 1996;41:1972–4. [PubMed]
3. Riquet M, Gandjbakhch I, Rabago G, Jault F, Dupont JC, Cabrol C. Isolated chylopericardium. Review of the literature apropos of a case [in French]. Ann Chir 1993;47:124–31. [PubMed]
4. Svedjeholm R, Jansson K, Olin C. Primary idiopathic chylopericardium–a case report and review of the literature. Eur J Cardiothorac Surg 1997;11:387–90. [PubMed]
5. Mahon NG, Nolke L, McCann H, Sugrue D, Hurley J. Isolated chylopericardium. Surgeon 2003;1:236–8. [PubMed]
6. Makaryus AN, Matayev S, Rosman D. A case of posterior lo-culated tamponade masquerading as an atrial mass on transesophageal echocardiography. J Ultrasound Med 2005;24: 873–6. [PubMed]
7. Nanjo S, Yamazaki J, Tsubuku M, Ohyama T, Ohtsuka T, Nakano H. Primary idiopathic chylopericardium: report of two cases. Ann Nucl Med 2004;18:537–9. [PubMed]
8. Cho BC, Kang SM, Lee SC, Moon JG, Lee DH, Lim SH. Primary idiopathic chylopericardium associated with cervicomediastinal cystic hygroma. Yonsei Med J 2005;46:439–44. [PMC free article] [PubMed]
9. Abadoglu O, Osma E, Ucan ES, Cavdar C, Akkoc N, Kupelioglu A, Akbaylar H. Behcet's disease with pulmonary involvement, superior vena cava syndrome, chyloptysis and chylous ascites. Respir Med 1996;90:429–31. [PubMed]
10. Mehrotra S, Peeran NA, Bandyopadhyay A. Idiopathic chylopericardium: an unusual cause of cardiac tamponade. Tex Heart Inst J 2006;33:249–52. [PMC free article] [PubMed]
11. Mood G, Shaaraoui M, Allareddy R, Smith D, Rodriguez L, Hammer D, Kalahasti V. Chylous pericardial effusion after minimally invasive mitral valve repair. Ann Thorac Surg 2006; 82:1892–4. [PubMed]
12. Lee N, Coco M. Chylous pericardial tamponade in a haemodialysis patient with catheter-associated thrombosis of internal jugular and subclavian veins. Nephrol Dial Transplant 2006; 21:2650–3. [PubMed]
13. Hovland A, Bjornstad H. Pericardial effusion in a patient with lymphangioleiomyomatosis. Scand J Infect Dis 2004;36:521–2. [PubMed]
14. Mogulkoc N, Onal B, Okyay N, Gunel O, Bayindir U. Chylothorax, chylopericardium and lymphoedema–the presenting features of signet-ring cell carcinoma. Eur Respir J 1999; 13:1489–91. [PubMed]
15. Khattab T, Smith S, Barbor P, Ghamdi SA, Abbas A, Fryer C. Extramedullary relapse in a child with mixed lineage acute lymphoblastic leukemia: chylous pleuropericardial effusion. Med Pediatr Oncol 2000;34:274–5. [PubMed]
16. Swelstad MR, Frumiento C, Garry-McCoy A, Agni R, Weigel TL. Chylotamponade: an unusual presentation of Gorham's syndrome. Ann Thorac Surg 2003;75:1650–2. [PubMed]
17. Serlo WS, Heikkinen E. Cardiac tamponade caused by a mediastinal teratoma. Scand J Thorac Cardiovasc Surg 1983;17: 323–5. [PubMed]
18. Yoshida K, Yamanda T, Aoki T, Miyazawa M, Hanniuda M, Amano J. A case of mature teratoma perforated into the pericardial cavity [in Japanese]. Nippon Kyobu Geka Gakkai Zasshi 1997;45:1107–10. [PubMed]
19. Sakamoto K, Kase M, Mo M, Kurata H. Mediastinal mature teratoma perforated into the pericardial sac: a case report [in Japanese]. Kyobu Geka 2000;53:74–7. [PubMed]
20. Marsten JL, Cooper AG, Ankeney JL. Acute cardiac tamponade due to perforation of a benign mediastinal teratoma into the pericardial sac. Review of cardiovascular manifestations of mediastinal teratomas. J Thorac Cardiovasc Surg 1966;51: 700–7. [PubMed]
21. Maeyama R, Uchiyama A, Tominaga R, Ichimiya H, Ku-roiwa K, Tanaka M. Benign mediastinal teratoma complicated by cardiac tamponade: report of a case. Surg Today 1999; 29:1206–8. [PubMed]
22. Oomman A, Santhosham R, Vijayakumar C, Jayaraman S, Ramachandran P, Kumar S. Anterior mediastinal teratoma presenting as cardiac tamponade. Indian Heart J 2004;56:64–6. [PubMed]
23. Smahi M, Achir A, Chafik A, al Aziz AS, el Messlout A, Benos-man A. Mature teratome of the mediastinum [in French]. Ann Chir 2000;125:965–71. [PubMed]
24. Guzzardi G, Natrella M, Barini M, Leutner M, Cotroneo AR. Mature teratoma of the anterior mediastinum: a case report [in Italian]. Radiol Med (Torino) 2001;102:180–3. [PubMed]
25. Kimura C, Kamiyoshihara M, Sakata K, Itoh H, Morishita Y. Mediastinal mature teratoma perforating into the lung with elevated serum carbohydrate antigen 19–9 (CA19-9) levels; report of a case [in Japanese]. Kyobu Geka 2003;56:247–50. [PubMed]
26. Ozergin U, Gormus N, Aribas OK, Durgut K, Yuksek T. Benign mature cystic teratoma of the anterior mediastinum leading to heart failure: report of a case. Surg Today 2003;33: 518–20. [PubMed]
27. Ege G, Akman H, Kuzucu K, Kalayci G. Spontaneous rupture of mediastinal cystic teratoma (case report) [in Turkish]. Tani Girisim Radyol 2004;10:127–30. [PubMed]
28. Golash V. A giant anterior mediastinal teratoma presenting as orthopnea and dysphagia in an adult. J Thorac Cardiovasc Surg 2005;130:612–3. [PubMed]
29. Abadir S, Acar P, De Maupeou F, Baunin C, Railhac JJ, Du-lac Y, et al. Unusual association of chylopericardium and aortic hypoplasia in a neonate [in French]. Arch Mal Coeur Vaiss 2005;98:579–81. [PubMed]

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