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Acute radiation-induced pericarditis complicated by polymicrobial infectious pericarditis in a patient with
Kimberly L Yan1, Yoo Jin Lee2, Alan H Baik1,3
1Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.
Background:
Acute pericarditis is often caused by viral infections, autoimmune diseases, and radiation therapy (RT). Infectious pericarditis is rare and associated with high morbidity and mortality. We present a case of acute RT-induced pericarditis complicated by bacterial pericarditis and cardiac tamponade due to oesophageal bacterial translocation.
Case Summary:
A 65-year-old man with a recurrent mediastinal sarcoma complicated by oesophageal compression and recent oesophageal stenting presented with shortness of breath. Electrocardiogram showed diffuse ST elevations, and he was diagnosed with presumed RT-induced pericarditis. Despite anti-inflammatory therapy, he developed haemodynamic instability and clinical tamponade, with transthoracic echocardiogram showing a large circumferential pericardial effusion. He underwent emergent pericardiocentesis, and pericardial fluid cultures grew polymicrobial species. Anti-inflammatories were held, and he was started on broad spectrum intravenous antibiotics and antifungals. Due to clinical decompensation and repeat computed tomography imaging demonstrating worsening pericardial disease, he underwent pericardial irrigation and subxiphoid pericardial window. The patient died from hypoxaemic and hypercapnic respiratory failure. Autopsy revealed constrictive pericarditis and no bacterial organisms in the pericardium.
Discussion:
Anti-inflammatories are standard treatment for viral and RT-induced pericarditis. Purulent, bacterial pericarditis is rare and an uncommon complication of RT-induced pericarditis. Polymicrobial infectious pericarditis is often refractory to intravenous antibiotics, requiring surgical intervention. This case highlights the importance of maintaining a high index of suspicion of various potential aetiologies of pericarditis in order to tailor medical and surgical therapies especially in high-risk, immunosuppressed cancer patients.
Insights
This case details a patient with radiation therapy-induced pericarditis who developed a rare bacterial pericarditis complication. Early suspicion and tailored treatment are crucial for high-risk cancer patients with pericardial disease.
Area of Science:
- Cardiology
- Oncology
- Infectious Diseases
Background:
- Acute pericarditis commonly stems from viral infections, autoimmune conditions, or radiation therapy (RT).
- Infectious pericarditis, though rare, carries significant morbidity and mortality risks.
- This case examines acute RT-induced pericarditis complicated by bacterial pericarditis and cardiac tamponade.
Observation:
- A 65-year-old man with mediastinal sarcoma and esophageal stenting presented with shortness of breath and ST elevations, initially presumed to be RT-induced pericarditis.
- Despite anti-inflammatory treatment, the patient developed hemodynamic instability and cardiac tamponade, with pericardial fluid cultures revealing polymicrobial species.
- Worsening pericardial disease led to surgical intervention, but the patient ultimately succumbed to respiratory failure.
Findings:
- The patient experienced a rare complication of polymicrobial bacterial pericarditis superimposed on radiation-induced pericarditis.
- Despite broad-spectrum antibiotics and antifungals, the infection proved refractory, necessitating surgical pericardial intervention.
- Autopsy revealed constrictive pericarditis, with no bacterial organisms detected in the pericardium post-mortem.
Implications:
- This case underscores the importance of considering diverse etiologies in pericarditis, particularly in immunocompromised cancer patients.
- Prompt diagnosis and tailored medical and surgical management are critical for improving outcomes in complex pericarditis cases.
- Maintaining a high index of suspicion for infectious complications is vital in patients with radiation-induced pericarditis.
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