Epicardial Fat Necrosis Leading to Constrictive Pericarditis

BACKGROUND: Epicardial fat necrosis (EFN) is a rare, benign, self-limited cause of acute chest pain that can mimic life-threatening conditions such as acute coronary syndrome or pulmonary embolism. Accurate recognition on imaging is essential to prevent unnecessary invasive work-ups. CASE SUMMARY: We report a case of a 61-year-old man who presented with acute chest pain and tachycardia. Computed tomography angiography of the chest revealed a focal pericardial defect with herniation of epicardial fat and adjacent stranding, findings consistent with epicardial fat herniation and strangulation. These findings were not initially recognized. Six weeks later, the patient presented again with recurrent chest pain. Follow-up contrast-enhanced computed tomography showed a 14-mm anterior pericardial defect with decreased inflammatory changes, compatible with sequelae of prior EFN. The patient improved on ibuprofen and colchicine. DISCUSSION: This case highlights EFN as an under-recognized mimic of acute cardiopulmonary disease. TAKE-HOME MESSAGE: Awareness of characteristic imaging findings can avert misdiagnosis and facilitate appropriate conservative therapy.