1214

Abstract

Introduction: A 24 year old male United States soldier presented for care at the NATO military hospital at Kandahar Airfield, Afghanistan, with rapidly progressive dyspnea and orthopnea over two hours. He was normotensive and afebrile but tachycardic (131 beats/minute) and tachypneic (36 breaths/minute). Physical examination revealed jugular venous distension and muffled heart sounds. Laboratory studies were notable for a leukocyte count of 28,000 cells/mm3 (62% band forms). Cardiac ultrasonography demonstrated a large pericardial effusion with partial diastolic collapse of the right ventricle, consistent with tamponade. Intravenous ceftriaxone and vancomycin were administered, and the patient was taken for emergent pericardial drainage catheter placement with the drainage of 400 mL of purulent fluid. Septic shock and hypoxemic respiratory failure developed, requiring norepinephrine and endotracheal intubation. Severe hypoxemia and hypoperfusion persisted, requiring neuromuscular blockade. Analysis of the fluid demonstrated 110,000 neutrophils/mm3 and Gram-positive cocci. He was evacuated by critical care air transport to Bagram Airfield, near Kabul, and subsequently to Ramstein Air Base, Germany. En route, he developed recurrent tamponade on multiple occasions despite attempted drainage using intrapericardial tenecteplase and additional large-bore catheter placement. A subxiphoid pericardial window was performed at Bagram with drainage of 140 mL of purulent fluid and significant but transient improvement in his hemodynamics. Cultures of his pericardial fluid demonstrated Streptococcus anginosus. Ceftriaxone was continued, and he was weaned from mechanical ventilation and transported back to the United States. A second pericardial window was performed nine days after his initial presentation. Six months later, he had returned to his baseline state of health. Streptococcus anginosus, previously known as S. milleri, is a rare pathogen in healthy hosts. Only eight prior cases of pericarditis have been reported in the literature, all in older patients and often with underlying comborbidities. Unlike most streptococci, S. anginosus produces abscesses and loculations requiring aggressive drainage; three of the eight previously reported patients required pericardiectomy. Our patient's care was complicated by his diagnosis in an active combat theater; a robust forward-deployed critical care capability, both on the ground and in the air, facilitated an excellent outcome.