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Cardiac tamponade and constrictive pericarditis due to Actinomyces meyeri bacterial pericarditis: a case report
Joanne Eng-Frost1, Lewis Murray1, Scott Lorensini1
1Department of Cardiology, Flinders Medical Centre, Level 6, Flinders Drive, Bedford Park, SA 5042, Australia.
Background:
Purulent bacterial pericarditis (PBP) is a highly lethal infection of the pericardial space that arises as a complication of infective illnesses. Purulent bacterial pericarditis remains a diagnostic challenge given its non-specific clinical and investigative features and carries exceedingly high mortality rates due to fulminant sepsis and morbidity including constrictive pericarditis in survivors. We present our management of cardiac tamponade and subsequent constrictive pericarditis due to Actinomyces meyeri PBP.
Case Summary:
A 53-year-old Caucasian male presented with acute New York Heart Association Class IV dyspnoea and chest discomfort, in the context of multiple hospital presentations over the preceding 8 weeks due to presumed recurrent viral pericarditis. On this admission, initial transthoracic echocardiography (TTE) demonstrated a large asymmetric pericardial effusion for which he underwent urgent pericardiocentesis. Serial TTE post-pericardiocentesis, however, demonstrated effusion re-accumulation and effusive-constrictive pericarditis, confirmed on cardiac magnetic resonance imaging. Fluid culture was positive for A. meyeri. He was diagnosed with PBP, but his condition deteriorated despite appropriate intravenous antibiotic therapy, necessitating semi-urgent surgical pericardiectomy. He recovered well and was discharged on Day 10 post-operatively.
Discussion:
Unlike uncomplicated acute viral or idiopathic pericarditis, PBP portends a very poor prognosis if unrecognized and untreated. Diagnostic challenges persist given its rarity in modern clinical practice; however, PBP should be considered in cases of seemingly recurrent pericarditis. Multi-modal cardiac imaging and careful analysis of pericardial fluid including cultures and lactate dehydrogenase/serum ratios may assist in earlier recognition. In this case, source control and symptom relief were achieved only with combined intravenous antibiotics, surgical evacuation, and pericardiectomy.
Insights
Purulent bacterial pericarditis (PBP) is a rare but deadly infection. Early recognition and combined antibiotic and surgical treatment are crucial for managing cardiac tamponade and constrictive pericarditis caused by Actinomyces meyeri.
Area of Science:
- Cardiology
- Infectious Diseases
- Medical Microbiology
Background:
- Purulent bacterial pericarditis (PBP) is a severe infection with high mortality, often presenting with non-specific symptoms.
- PBP poses diagnostic challenges due to its rarity and non-specific clinical features, leading to delayed treatment and poor outcomes.
- Constrictive pericarditis is a potential long-term complication in survivors of PBP.
Observation:
- A 53-year-old male presented with recurrent symptoms initially presumed as viral pericarditis.
- Diagnostic imaging revealed a large pericardial effusion, leading to pericardiocentesis, but effusion re-accumulated, indicating effusive-constrictive pericarditis.
- Pericardial fluid culture identified Actinomyces meyeri as the causative agent of PBP.
Findings:
- Despite appropriate intravenous antibiotics, the patient's condition worsened, necessitating surgical pericardiectomy for source control.
- Combined antibiotic therapy, surgical evacuation, and pericardiectomy were essential for managing cardiac tamponade and effusive-constrictive pericarditis.
- The patient demonstrated a good recovery following surgical intervention and was discharged on postoperative day 10.
Implications:
- PBP should be considered in patients with recurrent pericarditis, even if initially presumed idiopathic or viral.
- Multi-modal cardiac imaging and pericardial fluid analysis, including cultures, are vital for early PBP diagnosis.
- Aggressive management combining antibiotics and surgical intervention is critical for improving outcomes in PBP patients with cardiac compromise.
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