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An unusual cause of pericardial effusion
 
Published on 2015-01-05 by Walid Gharzuddine
 
 
History and Findings
 

A 49-year-old Iraqi male presented in February 2011 to the American University of Beirut Medical Center with fever, and generalized weakness. He gave history of surgery for removal of a thymoma in India in four months earlier. The patient had been diagnosed in Iraq with myasthenia gravis five months prior to the surgery and was started on prednisone and mestinone at the time. About three weeks after the surgery the patient reportedly developed fever and chills for which he received treatment in India with no information available to us except that he was prescribed  Levofloxacin on discharge for about two weeks. The period from December 2010 until February 2011 in Iraq was characterized by recurrent chest pain, fever, chills, sweating, cough and greenish sputum production. Blood tests at that time showed a WBC of 26000/μl. Prior to presentation to AUBMC emergency room he underwent CT of the chest which showed multiple cystic masses impinging on the right ventricle and one behind the left atrium and ventricle (figures 1 & 2 cysts 1, 2 & 3) described as metastasis in concordance with his history of malignant thymoma. A PET CT scan again showed cystic masses in the chest with necrosis and invasion of the pericardium described as metastasis. Evaluation in the emergency room showed a sick-looking man with sinus tachycardia at a rate of 120 beats per minute. Systolic blood pressure ranged fro 80-90 mmHg which improved on fluid resuscitation. Echocardiography confirmed the presence of two large anterior fluid collections one of which was compressing the right ventricle with a third cyst behind the left atrium seen on the apical an parasternal long axis views. In view of the apparently significant compression of the right ventricle by the anterior fluid collection (videos 1, 2 &3) pericardiocentesis was performed. Surprisingly aspiration yielded 90 ml. of greenish yellow purulent fluid. The Gram stain showed Gram positive branching rods and the cultures grew Nocardia spp. later identified in the Lab. Cerba France as N. asiatica. CT scan of brain showed multiple cystic lesions so the patient was diagnosed as having disseminated Nocardia infection and was started on an antibiotic regimen consisting of imipenem, amikacin and trimethoprim-sulfamethoxazole

At this stage a median sternotomy was performed and debridement of the abscesses in the anterior mediastinum as well as biopsy of suspicious tissue was performed. The pathology did not reveal any malignancy. The posterior abscess could not be reached without instituting cardiopulmonary bypass and was left to be aspirated later by a gastroenterologist through the esophagus utilizing endoscopic ultrasound.

The patient was discharged on long-term antibiotic treatment on co-trimoxazole (one year). Re-evaluation by CT scan six months later showed complete resolution of the intra-thoracic (fig.4) and cerebral lesions. 

 
 
 
video 1 Ap. 4 Ch. | video 2 PSAX | video 3 PLAX
 
 
       
 
 
Discussion
 

Purulent pericarditis is usually a serious condition with high mortality if not managed aggressively. Most often it is due to contiguous spread from a streptococcal or staphylococcal pneumonia. Recommended treatment is initial drainage by pericardiocentesis followed by pericardiectomy and adequate drainage of the mediastinum. On the other hand, infection with Nocardia spp. occurs mainly in immuno-compromised patients and it is usually considered in the differential diagnosis when such patients present with pulmonary, brain or skin lesions. Our patient had two predisposing factors for infection with this type of organism: possible T cell dysfunction from questionnable malignant thymoma and corticosteroid use.

There are two reports of fatal pericardial involvement despite surgical intervention. One in a patient on steroids and azathioprine, the other in a morbidly obese patient with a body mass index of 41 (ref. 1 & 2). One patient who survived had negative culture of the pericardial fluid but positive tissue cultures for Nocardia (ref. 3). Other reports are in patients with HIV infection. (ref. 4 & 5) As far as treatment is concerned, there are no specific guidelines as the infection with such species is rare and the treatment options were not entertained in clinical trials.  Most of the treatment recommendations are based on animal models, basic research, case reports and expert opinions and usually consists of three antibiotics including imipenem or ceftriaxone, TMP-SMX and amikacin for at least one year with nervous system involvement.

Points of particular interest in this case are the importance of periardiocentesis in stabilizing the patient as well as allowing a diagnosis to be reached so that surgery could be planned and performed under appropriate antibiotic coverage. In addition endoscopic drainage of the retro-cardiac abscess was a novel option that may have contributed to the good outcome.

 

 

 

1. Francois Roubille, Guillaume Maxant, Isabelle Serre, Pascal Colson, Pascal Battistella, Brigitte Calvet, Bernard Albat and Jean-Luc Pasquié: Fatal Systemic Nocardia Infection Revealed by Cardiac Tamponade Inter Med 2010. 49: 135-137.

2. P. Hornick, P. Harris, P. Smith Eur J Cardio-thorac Surg 1995, 9: 468-470 Nocardia asteroides purulent pericarditis

3. Clenney TL, Hammond MD, McKeown PP, Holt DA, Wallach PM. Cardiac tamponade due to Nocardia asteroides. Chest 103: 641-642, 1993. 


4. Leang B, Lynen L, Lim K, Jacques G, Van Esbroeck M, Zolfo M. Disseminated nocardiosis presenting with cardiac tamponade in an HIV patient. Int J STD AIDS 15: 839-840, 2004.

5. Rivero A, Esteve A, Santos J, Ma!quez M. Cardiac tamponade caused by Nocardia asteroides in an HIV-infected patient. J Infect 40: 206-207, 2000. 

 
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jianbin0727 reply on 2017-07-27
 
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