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Published on: April 7, 2015
Purulent Pericarditis After Esophageal Erosion With Streptococcus intermedius and Lactobacillus spp
Vineet Madishetty1, Alexander Yaylayan1, Armaan Handa1
1Internal Medicine/Cardiology, HCA Healthcare/USF Morsani College of Medicine GME/HCA Florida Largo Hospital, Largo, Florida, USA.
Background:
Purulent pericarditis is rare but rapidly fatal without urgent drainage and targeted antibiotics; malignancy-related effusions should not be presumed malignant when an anatomic breach is possible.
Case Presentation:
A 67-year-old male with esophageal squamous cell carcinoma presented with pleuritic chest pain. Electrocardiogram showed diffuse ST elevation; transthoracic echocardiography revealed a large effusion with fibrinous strands and mild right-ventricle diastolic collapse. Computed tomography angiography demonstrated tumor erosion into the left main bronchus. The patient received vancomycin/piperacillin-tazobactam and underwent emergent pericardiocentesis yielding ∼800 mL of cloudy fluid (49,710 cells/μL, glucose 2 mg/dL, lactate dehydrogenase 7,327 U/L; neutrophil predominant; cytology negative; blood cultures returned negative). Cultures grew Streptococcus intermedius and Lactobacillus spp; antibiotics were narrowed to intravenous ceftriaxone for 3 weeks. Persistent tamponade necessitated pericardial window placement on hospital day 4; follow-up echocardiography demonstrated improved effusion with pericardial thickening/calcification.
Discussion:
In malignancy, diffuse ST elevation and highly inflammatory fluid should prompt evaluation for purulence and an anatomic breach rather than anchoring on malignant effusion.
Take-Home Message:
In cancer patients with pericardial effusion, oral/gastrointestinal flora in pericardial cultures should trigger evaluation for an anatomic breach (eg, tumor erosion) and early source control with drainage, culture-directed antibiotics, and surgical escalation when tamponade continues to persist.
Insights
Purulent pericarditis in cancer patients can mimic malignant effusions. Look for signs of infection and anatomic breaches, like tumor erosion, to guide urgent treatment.
Area of Science:
- Cardiology
- Oncology
- Infectious Diseases
Background:
- Purulent pericarditis is a rare but life-threatening condition requiring prompt intervention.
- Malignancy-associated pericardial effusions can obscure diagnoses, necessitating careful evaluation.
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