Purulent Pericarditis Presenting as Acute Coronary Syndrome

1
Purulent Pericarditis Presenting as Acute
Coronary Syndrome
Linda Nabha, MD1 Aderemi Soyombo, MD2 Julio A.
Panza, MD2
1Department of Medicine, Georgetown University
Hospital, Washington, DC 2Washington Hospital
Center, Washington, DC
Georgetown University
Abstract
Case Description (continued)
INTRODUCTION Purulent pericarditis is a rare but
usually fatal disease. The clinical recognition
of purulent pericarditis remains difficult
because of its variable presentation. Thus while
purulent pericarditis can present as an
infectious syndrome, it can also mimic an acute
coronary syndrome. CASE REPORT A 61-year-old
African-American male with a history of
membranous glomerulonephritis, hypertension, and
diabetes mellitus was admitted for chest pain and
shortness of breath. The patient was taken for
primary percutaneous intervention secondary to
EKG changes suggestive of an ACS. Coronary
angiography showed an 80 stenotic lesion in the
right coronary artery and successful PCI with
stent placement was performed. During the
procedure, the patient became hemodynamically
unstable. A transthoracic echocardiogram showed
a large pericardial effusion. A therapeutic and
diagnostic pericardiocentesis was performed
resulting in hemodynamic improvement. Cultures
from the pericardial fluid grew
methicillin-sensitive Staphylococcus aureus. The
patient was started on antibiotics and fluid
resuscitated. A pericardial window and chest
tubes for drainage of bilateral pleural effusions
were subsequently performed. The patient remained
in critical care on antibiotics in the intensive
care unit. DISCUSSION This case highlights
multiple important concepts. First, the
diagnosis of purulent pericarditis requires a
high index of suspicion. Second, it is often
difficult to distinguish ACS from other causes of
chest pain. The EKG changes and elevated cardiac
markers in this case were a result of purulent
pericarditis and not ACS. CONCLUSION Purulent
bacterial pericarditis is associated with
considerable morbidity and death. Hence, it is
imperative to recognize this disease in its early
stages in order to adopt an aggressive management
in a timely fashion. Purulent pericarditis may
mimic the signs and symptoms of ACS. Good history
taking, EKGs, and cardiac markers remain the key
tests to acutely diagnose ACS. However, careful
clinical evaluation remains the most important
factor in the appropriate diagnosis.
Fig. 1(A-B). Figure A shows an 80 stenotic
lesion of the mid right coronary artery. Figure
B shows successful angioplasty resulting in TIMI
III flow.
Initial CCU Course The patient was
transferred to the Coronary Care Unit for further
management. Upon arrival, an echocardiogram
revealed a large circumferential pericardial
effusion. The patient underwent
pericardiocentesis1, which yielded approximately
800 cc of turbid, bloody fluid. Following the
procedure, the patients blood pressure improved
dramatically and pressors were weaned. Broad
spectrum antibiotics were started.
Fig. 2. TRANSTHORACIC ECHOCARDIOGRAM There is a
circumferential pericardial fluid that measures
2.9 cm inferiorly and 2.3 cm laterally. Left
ventricular function was grossly normal.
Ejection Fraction 55-60. All valves were
grossly normal.
Subsequent Clinical Course Subsequent cultures
of pericardial fluid produced methicillin-sensitiv
e Staphylococcus aureus (MSSA). Antibiotics were
appropriately changed to Nafcillin IV.
Despite fluid resuscitation and adequate
antibiotic coverage, the patients status did not
improve. On day 5, blood cultures were positive
for MSSA. The patient was taken to the operating
room where he underwent a pericardial window, and
chest tubes were placed for drainage of
bilateral pleural effusions. Fluid
resuscitation and IV antibiotics were continued.
Chest tubes were subsequently removed. An
echocardiogram on day 14 revealed near resolution
of the pericardial effusion. The patient
remained in the CCU for several days before
transferring to a lower level of care.
Introduction
In the antibiotic era, purulent pericarditis has
become a rare entity. Its clinical recognition
remains difficult because its presentation may
vary from case to case. However, early
recognition of purulent pericarditis is essential
for survival. While purulent pericarditis may
often present with fevers, shortness of breath,
and chest pain, it can also present as an acute
coronary syndrome. We report a case of purulent
pericarditis presenting as ACS.
Discussion
Case Description
The diagnosis of purulent pericarditis
requires a high index of suspicion.
Unfortunately, it is most often made at autopsy,
and mortality remains high in diagnosed cases
despite aggressive drainage and prolonged
antibiotic therapy. Thus early diagnosis of
purulent pericarditis is essential to survival.
The most common cause of purulent pericarditis
in the antibiotic era is Staphylococcus aureus.2
In a study by Rubin et al. in 26 patients
with purulent pericarditis, Staphylococcus
aureus was responsible for 31 of the cases
(table 1).3 In our patient, records from the
outside hospital revealed axillary abscess
cultures positive for MSSA. The patient likely
became bacteremic and the infection seeded to the
pericardium. The patients immunosuppressed state
may have (1) inhibited the ability for an
appropriate immune response and (2) predisposed
the patient for infection. It is often
difficult to distinguish ACS from other causes of
chest pain. The EKG changes and elevated cardiac
markers in this case were a result of purulent
pericarditis and not ACS.
Initial Presentation A 61-year-old
African-American male presented to the emergency
department with chest pain and shortness of
breath. His past medical history was significant
for hypertension, diabetes mellitus, coronary
artery disease, and membranous glomerulonephritis
on oral steroid therapy. One month earlier,
he was treated at an outside hospital for an
axillary abscess which was drained and a full
course of antibiotics was given. In the
emergency department, the patient was found to be
tachypneic, tachycardic, and afebrile.
Laboratory values were notable for CK-MB 5.3
Ng/ml, Troponin I 1.07 Ng/ml, and a white
blood cell count 28.9 K/µL. Initial EKG
showed ST elevations in leads II, III, aVF, V5,
V6 and t-wave inversions in leads
V2-V5. Initial Management The patient was
taken for immediate cardiac catheterization for
suspected acute coronary syndrome. The patient
was intubated upon arrival to the cath lab for
respiratory distress. An 80 stenotic lesion
was found in the mid right coronary artery and
was effectively stented. During the procedure
the patient became hemodynamically unstable and
an intra-aortic balloon pump was placed.
Norepinephrine was started for hypotension. A
right heart catheter was placed which showed the
following Central
Venous Pressure19 mmHg, Pulmonary Artery
Pressure46/20 mmHg, Wedge Pressure
20 mmHg, Cardiac Output3.1 L/min, Systemic
Vascular Resistence1057 dynes- second/
cm5.
TABLE 1
Conclusions
In patients with chest pain, tests cannot replace
clinical judgment, and there remains no
substitute for careful clinical evaluation when
formulating a diagnosis or treatment plan. It is
oftentimes difficult to distinguish ACS from
other causes of chest pain. It is also important
to keep in mind elevated cardiac markers may not
reflect myocardial ischemia. While good history
taking, EKGs, and cardiac markers remain the key
tools to evaluate for ACS, careful clinical
evaluation remains the most important factor in
the appropriate diagnosis.
.
References
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Purulent pericarditis and pleural empyema due to
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Journal of Cardiology. Feb 2008 124(1)108,. 3.
Rubin RH, Moellering RC Jr. Clinical,
microbiologic and therapeutic aspects of purulent
pericarditis. Am J Med 1975596878.