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Pyo-pericardium secondary to bacteremia in intra-venous drug user

Published:September 16, 2022DOI:https://doi.org/10.1016/j.amjms.2022.09.002

      Abstract

      Pyo-pericardium is a collection of purulent fluid in the pericardial sac. It is a rare finding seen in less than 1% of patients who develop acute pericarditis. The condition, though uncommon, has a mortality risk of 100% in untreated patients and 40% in treated patients. Most of the reported cases in the literature describe the occurrence of pyo-pericardium in IV drug users that's secondary to needle fragment embolization to the pericardium diagnosed through an echocardiogram and CT scan with no evidence of bacteremia. Unlike reported cases, we present a case of pyo-pericardium in a 37-year-old woman with bacteremia from a wound infection on her leg secondary to IV drug use. Needle embolization was ruled out in our case as no foreign object was identified on echocardiography or CT scan. Prompt identification followed by aggressive treatment with pericardial window and systemic antibiotics is crucial for decreasing mortality in such high-risk patients.

      Key Indexing Terms

      Introduction

      Pyo-pericardium used to be a common condition in the past; however, the number of patients with this condition have reduced drastically after the introduction of antibiotics. Today, we see <1% of patients with pericarditis developing pyo-pericardium.
      • Cracknell B.R.S.
      • Ail D
      The unmasking of a pyopericardium.
      The mortality rate remains high even with treatment. We present a severe case of a 37-year-old female with a known history of IV drug abuse presenting with methicillin-sensitive Staphylococcus Aureus bacteremia and pyo-pericardium.

      Case presentation

      A 37-year-old female presented to the emergency department with complaints of shortness of breath, dyspnea at rest, chest pain, cough, fever, and chills. In addition, she reported severe pain and swelling in her left lower extremity, which made her unable to ambulate, along with weakness and fatigue. The patient was known to be a daily IV drug user of heroin and methamphetamine. On physical examination, she was tachypneic with a respiratory rate of 41/min, Heart rate was 99/min, Blood pressure was 120/55 mmHg, and oxygen saturation was 95% on room air. There was a necrotic soft tissue infection with purulent drainage in her left lower extremity, as shown in (Fig. 1). Her laboratory workup was remarkable for WBC of 36.67 K/mL, hemoglobin of 9 g/dL, hematocrit of 26.9%, and lactic acid of 2.7 mmol/L; however, her kidney function was within normal range. EKG showed wandering pacemaker pattern (Fig. 2). Computed Tomography (CT) scan of the chest showed pericardial effusion and bilateral pulmonary lesions, which were consistent with septic emboli (Fig. 3). The transthoracic echocardiogram confirmed pericardial effusion (Fig. 4) with evidence of tamponade physiology; however, she remained hemodynamically stable (Fig. 5). Despite having tamponade physiology on the TTE, there was no signs of Beck's triad on physical exam. Blood cultures and sputum cultures were persistently positive for methicillin-sensitive Staphylococcus Aureus infection but negative for other micro-organisms including fungi. The patient did not have stigmata of endocarditis. Patient was initially commenced on Vancomycin, Clindamycin and Cefepime which was then changed to nafcillin based on sensitivity results.
      Fig 1
      FIGURE 1Necrotic soft tissue infection of the left lower extremity.
      Fig 2
      FIGURE 2Electrocardiogram showing wandering pacemaker pattern.
      Fig 3
      FIGURE 3Computed tomography scan of the chest demonstrating septic emboli and pericardial effusion.
      Fig 4
      FIGURE 4Echocardiogram demonstrating pericardial effusion.
      Fig 5
      FIGURE 5Echocardiography showing a mitral inflow variability of 28%, which is consistent with cardiac tamponade.
      The patient underwent a subxiphoid 3 × 3 pericardial window with drainage of several hundred CC of murky yellowish fluid. Intraoperative transesophageal echocardiography revealed near-resolution of the pericardial effusion (Fig. 6). There was no evidence of tricuspid endocarditis on neither the TTE done on admission, nor the TEE done intra-operatively. Pericardial fluid pathology revealed many white blood cells with histiocytes and mesothelial cells with no signs of malignancy, few gram-positive cocci in chains and clusters, and rare gram-positive rods. The pericardial fluid did grow MSSA. Pericardial tissue biopsy showed evidence of fibrosis but negative for TB infection. Postoperatively, the patient remained intubated for 2 days. She was extubated on day 3 and was placed on 5 L oxygen via nasal cannula. On Day 4, the patient was in severe respiratory distress and altered mental status in addition to worsening of the wound on her left lower extremity; thus, she was reintubated and started on vasopressors (norepinephrine and phenylephrine). At that time, septic shock from the leg wound was the possible diagnosis. General surgery deferred any incision and drainage procedure at that time as the patient was unstable and required vasopressors. She then developed pulseless electrical activity (PEA) on post-operative day 6, received multiple rounds of resuscitation attempts with no achievement of return of spontaneous circulation, and she was pronounced dead.
      Fig 6
      FIGURE 6Echocardiogram after pericardial window demonstrating complete drainage of pericardial fluid.

      Discussion

      Purulent pericarditis, or pyo-pericardium, is a rare condition involving a collection of purulent fluid within the pericardial sac secondary to a bacterial infection. The mortality rate of pyo-pericardium is 100% in untreated patients and 40% in treated patients.

      Gopalakrishnan M., Manappallil R.G., Nambiar H., et al. Pyopericardium progressing to tamponade in a patient with immune thrombocytopenia. BMJ Case Rep. 2018;2018:bcr2018225009. https://doi.org/10.1136/bcr-2018-225009

      Purulent pericarditis is usually caused by gram-positive organisms, which account for 40 to 45 percent of all infections. S. aureus is the most common cause of purulent pericarditis, accounting for around 31 percent of cases. Polymicrobial infections are uncommon. S. pneumoniae is the most common cause of purulent pericarditis in the direct spread of infection from an intrathoracic focus.
      • Rubin R.H.
      • Moellering Jr, R.C
      Clinical, microbiologic and therapeutic aspects of purulent pericarditis.
      ,
      • Sagristà-Sauleda J.
      • Barrabés J.A.
      • Permanyer-Miralda G.
      • et al.
      Purulent pericarditis: review of a 20-year experience in a general hospital.
      Tuberculosis is the most common cause of subacute or chronic purulent pericarditis, especially where the prevalence of HIV is high. Other rare organisms have been reported to cause purulent pericarditis, like Salmonella and anaerobes.
      • Parikh S.V.
      • Memon N.
      • Echols M.
      • et al.
      Purulent pericarditis: report of 2 cases and review of the literature.
      Also, fungal pathogens have become more common causes of purulent pericarditis, especially in those who have predisposing factors for candidemia. Hence, broad-spectrum antibiotics should be started immediately to cover the most common organisms.
      • Rubin R.H.
      • Moellering Jr, R.C
      Clinical, microbiologic and therapeutic aspects of purulent pericarditis.
      ,
      • Sagristà-Sauleda J.
      • Barrabés J.A.
      • Permanyer-Miralda G.
      • et al.
      Purulent pericarditis: review of a 20-year experience in a general hospital.
      There are two main mechanisms by which patients can develop purulent pericarditis: The most common one is direct spread from an intrathoracic focus of infection or extension from a subdiaphragmatic suppurative focus. This can include trauma, thoracic surgery, catheter drainage, pneumonia, empyema, retropharyngeal and hepatic/subdiaphragmatic abscess, and perivalvular abscess rupture in endocarditis. The second one is hematogenous spread in bacteremia, which is very rare.

      Gopalakrishnan M., Manappallil R.G., Nambiar H., et al. Pyopericardium progressing to tamponade in a patient with immune thrombocytopenia. BMJ Case Rep. 2018;2018:bcr2018225009. https://doi.org/10.1136/bcr-2018-225009

      ,
      • Little W.C.
      • Freeman G.L
      Pericardial disease.
      Bacterial pericarditis can lead to pericardial effusion. The pressure on the heart from the fluid may lead to cardiac tamponade showing signs of Beck's triad – hypotension, venous distension, and distant heart sounds. However, tamponade may not develop in every case, and patients rarely present with all three components. Pyo-pericardium may also be accompanied by ST elevations due to pericarditis; however, electrocardiography is non-specific and non-sensitive for purulent pericarditis. Hence, definite diagnosis must be made through echocardiography and fluid aspiration followed by culturing of the organism.

      Gopalakrishnan M., Manappallil R.G., Nambiar H., et al. Pyopericardium progressing to tamponade in a patient with immune thrombocytopenia. BMJ Case Rep. 2018;2018:bcr2018225009. https://doi.org/10.1136/bcr-2018-225009

      ,
      • Hall I.P
      Purulent pericarditis.
      Other imaging modalities such as CT and MRI may also prove helpful.
      IV drug users are susceptible to several infections, which may be localized or systemic. These may include cellulitis of the injection site, necrotizing fasciitis, endocarditis, and sepsis.
      • Lavender T.W.
      • McCarron B
      Acute infections in intravenous drug users.
      Symptoms of sepsis should raise concerns of bacteremia in IV drug users as direct inoculation of bacteria into the bloodstream can occur. A study assessing hospitalizations due to IV drug use reported an 18-fold increase in hospitalizations due to bacteremia in this population.
      • Capizzi J.
      • Leahy J.
      • Wheelock H.
      • et al.
      Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018.
      In addition, bacteremia may infect other organs, including the heart, leading to bacterial pericarditis, which may give rise to a rarer form of acutely fulminant and rapidly fatal purulent pericarditis.
      • Pankuweit S.
      • Ristić A.D.
      • Seferović P.M.
      • et al.
      Bacterial pericarditis: diagnosis and management.
      This case is a rare event of purulent pericarditis secondary to bacteremia due to IV Drug use. Few cases in the literature were found presenting similarly due to heroin use.
      • Basman C.
      • Patel Y.
      • Shalonov A.
      • et al.
      Epidemic of heroin: purulent pericardial effusion and septic emboli in an intravenous drug user with right sided endocarditis.
      Other cases have been reported describing the occurrence of pyo-pericardium in IV drug users; however, this was secondary to needle fragment embolization to the pericardium diagnosed through an echocardiogram and CT scan with no evidence of bacteremia.
      • Steiner J.
      • Dhingra R.
      • Devries J.T
      Needle in the haystack: purulent pericarditis from injection drug use.
      Needle embolization was ruled out in the present case as no foreign object was identified on echocardiography or CT scan.
      Treatment of pyo-pericardium involves immediate broad-spectrum antibiotic therapy with drainage of the purulent fluid. Depending on the progression of the disease, pericardiocentesis, subxiphoid pericardiotomy, or pericardiectomy can be done for fluid drainage. Subxiphoid pericardiotomy is the commonly used method as it has lower chances of developing post-operative pericardial constriction, unlike pericardiocentesis.
      • Pankuweit S.
      • Ristić A.D.
      • Seferović P.M.
      • et al.
      Bacterial pericarditis: diagnosis and management.
      Pericardiectomy is associated with higher morbidity and mortality; however, it is preferred over subxiphoid pericardiotomy in cases with thick purulent fluid with dense adhesions.
      • Pankuweit S.
      • Ristić A.D.
      • Seferović P.M.
      • et al.
      Bacterial pericarditis: diagnosis and management.
      ,
      • Kondapi D.
      • Markabawi D.
      • Chu A.
      • et al.
      Staphylococcal pericarditis causing pericardial tamponade and concurrent empyema.
      The drained fluid must be cultured to find the causative organism and treated with targeted antibiotics for 2–4 weeks. The pericardial catheter may be left inside to allow complete drainage and to prevent the possible recurrence of effusion.

      Conclusions

      Pyo-pericardium is a rare occurrence in this era due to advancements in antibiotics. However, certain high-risk populations such as IV drug users may be susceptible to developing this condition. Prompt recognition of the primary source of hematogenous spread and early diagnosis and treatment is imperative due to the high risk of mortality if treatment is delayed.

      Authors contribution

      All authors contributed to manuscript writing and editing after Dr.Abidi wrote the first draft.

      Conflicts of interest

      The authors have no financial conflicts to disclose.

      Source of Funding

      The authors have no funds to disclose.

      Patient's consent

      The patient gave a permission for the case to be published.

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