Case Presentation: A 15-year-old female was transferred to our facility with a complaint of worsening chest pain for the previous two weeks. The pain initially started in her shoulders and then spread to her substernal area. She had initially presented to the same facility three days previously and was discharged with a diagnosis of musculoskeletal chest pain. On admission, she denied any fevers or chills. An electrocardiogram showed sinus tachycardia with flattened T waves. Computed tomography did not show any pulmonary emboli but did show a large pericardial effusion. The CT scan also showed left lower lobe consolidation and small bilateral pleural effusions. A 2.3 cm enhancing mass was also found in the left hepatic lobe. On admission to our facility, she was tachycardic and her physical examination was significant for bibasilar decreased breath sounds and muffled heart sounds. Laboratory studies were significant for normocytic anemia and elevated inflammatory markers. Her troponins and BNP were normal. An echocardiogram showed a large pericardial effusion, and pericardiocentesis with chest tube placement was subsequently performed. Blood cultures and pericardial fluid cultures showed no growth. The pericardial fluid was consistent with an exudate.
Discussion: She was started on naproxen and furosemide for acute pericarditis and colchicine was later initiated. Viral studies of the pericardial fluid including EBV, HIV, CMV, Parvovirus, and Enterovirus were negative. Lyme serology, thyroid studies, and antistreptolysin O titers were normal. Additionally, ANA, cANCA, pANCA, and alpha feto-protein were also normal. A cardiac MRI showed no evidence of pericardial masses. Though no clear cause of her pericardial effusion was found, magnetic resonance imaging of the liver was ordered and showed a heterogeneous left hepatic lobe mass suggestive of a hemorrhagic adenoma. Focal nodular hyperplasia and myofibroblastic tumor were also considered but were less likely. She did well during her hospital course and demonstrated improvement in serial echocardiograms. Her inflammatory markers also improved. She had complete resolution of her pericardial effusion on echocardiogram nine months after discharge.
Conclusions: The finding of a hemorrhagic hepatic adenoma in the setting of a pericardial effusion is unique and has not been described in the literature. Hepatic adenomas are benign neoplasms that are often found in women who use oral contraceptives, though this patient did not have any risk factors.