case_images: PMC6590561_01
case_images: (a) Chest radiograph showing nodular opacities in the bilateral upper lung and diffuse small nodules throughout the lung field. (b) Transthoracic echocardiogram revealing a massive pericardial effusion. PE: pericardium effusion; LA: left atrium; LV: left ventricle; Ao: aorta; RV: right ventricle. (c) Computed tomography revealing a massive pericardial effusion. PE: pericardium effusion.
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case_images: PMC6590561_01_CRIC2019-5068580.001.jpg
case_images: fig1
case_images: A chest radiograph revealed cardiomegaly; his cardiothoracic ratio was 61.0% (Figure 1(a)). Opaque nodules measuring ~30 mm were observed bilaterally in the upper lung, and diffuse, small nodules were observed throughout the lung field and hilar region (Figure 1(a)). Transthoracic echocardiography and chest computed tomography both revealed massive pericardial effusion (Figures 1(b) and 1(c)). Additional findings on echocardiography included not only a right atrium collapse but also a hyperechoic pericardium and pericardial thickening (Figure 1(b)).
case_images: (a) Multiple white, nodular deposits (yellow arrows) observed throughout the pericardium. (b) Pericardial fenestration was performed using the Harmonic Scalpel . White nodular-like deposits (triangle) were found throughout the pleura and pericardium.
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case_images: PMC6590561_01_CRIC2019-5068580.002.jpg
case_images: fig2
case_images: Thoracoscopic examination again revealed serous pleural effusion and multiple nodular opacities throughout the pleura and pericardium (Figures 2(a) and 2(b)). A small incision was made on the pericardium (Figure 2(b)), taking care to preserve the left phrenic nerve, through which approximately 1200 mL of the effusion fluid was drained.
case_images: (a) Macroscopic findings of the resected pericardium. (b) Hematoxylin and Eosin staining revealed chronic infiltration of inflammatory cells and hyalinized fibrosis within the white nodular tissue of the resected pericardium.
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case_images: PMC6590561_01_CRIC2019-5068580.003.jpg
case_images: fig3
case_images: Cytological examination of the pericardial biopsy sample was unremarkable; however, histopathological examination revealed inflammatory cell (mainly lymphocytes) infiltration and hyalinized fibrosis within the nodular tissue (Figures 3(a) and 3(b)), consistent with a diagnosis of silicosis.