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.
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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.