Background: Epipericardial fat necrosis (EFN), also known as pericardial, epicardial or mediastinal fat necrosis, is a rare cause of acute chest pain. It is a benign, self-limited condition with an unknown pathophysiology. The diagnosis of EFN can protect the patient from undergoing unnecessary invasive diagnostic or therapeutic measures. 

Case description: A 85-year-old woman presented to the emergency department with acute, left-sided, sharp, pleuritic pain of the chest (numeric rating scale 10/10) associated with a pain-induced inability of deep inspiration. The patient had a history of non-Hodgkin lymphoma and recent duodenal ulcer with gastrointestinal bleeding. ECG showed sinus rhythm with a heart rate of 75 beats per minute and left axis deviation without ST segment changes. High-sensitive troponin T was mildly elevated (0.027 ng/ml, normal < 0.015 ng/ml) with no significant change after 3 hours. Serum levels of D-dimer, creatine kinase (CK) and CK-MB were within normal range. C-reactive protein was substantially increased with 81.7 mg/l (< 5.0 mg/l). Intravenous morphine at a dose of 15 mg was initially administered intravenously for pain relief without achieving sufficient analgesia. Subsequently, a chest and abdominal computed tomography (CT) scan including pulmonary and aortic angiography was performed showing no evidence of pulmonary embolism and aortic dissection but a soft tissue lesion with inflammatory changes adjacent to the thickened pericardium located on the left lateral aspect of the heart was noted. Thus, the diagnosis of EFN was made and treatment with metamizole initiated. After 3 days, chest pain resolved and the patient was discharged without further pain medication.

Conclusion: EFN is a rare, benign cause of acute chest pain that can be readily diagnosed using CT or cardiomagnetic resonance (CMR). Physicians working in the chest pain unit should be aware of this entity to avoid unnecessary invasive procedures. Treatment should be restricted to analgesia since the disease is self-limited.