Case Report: Acute methicillin-sensitive Staphylococcus aureus pericarditis in a diabetic patient

Bacterial pericarditis is rare in the antibiotic era but remains potentially fatal due to rapid progression and high mortality. Herein, we report an unusual case of methicillin-sensitive Staphylococcus aureus (MSSA) pericarditis with a transudative pleural effusion in a patient with poorly controlled type 2 diabetes mellitus (DM), illustrating the diagnostic and therapeutic challenges in a complex patient.

A 47-year-old female patient with a history of presumptive ischemic cardiomyopathy, uncontrolled DM (a glycated hemoglobin level of 14.2%), and treated pulmonary tuberculosis (TB) presented with pleuritic chest tightness, fever, and dyspnea. Examinations and investigations revealed a moderate-to-large pericardial effusion, ST-segment elevation on an electrocardiogram, and high inflammatory markers. Imaging showed a pericardial effusion, raising suspicion for bacterial pericarditis. Pleural tap of an adjacent pleural effusion nearby was however transudative.

Pericardiocentesis was not feasible due to the loculated pericardial effusion and absence of a safe window; however, S. aureus was detected by polymerase chain reaction testing of the patient's pleural fluid. Cardiothoracic surgeons performed a pericardial window and biopsy, confirming MSSA pericarditis. Surgical drainage was successful and the patient completed 6 weeks of intravenous cefazolin with full recovery.

This case emphasizes the need to consider bacterial etiologies, including MSSA, when evaluating pericarditis in immunocompromised patients, especially those with DM or prior TB. Multimodal imaging, molecular diagnostics, and early surgical consultation are important in cases where pericardiocentesis is not feasible. Invasive diagnostic strategies may be critical for achieving a microbiological diagnosis and ensuring timely source control. Multidisciplinary collaboration is essential when managing complex pericardial infections to optimize diagnostic certainty and outcomes.