A CASE OF EFFUSIVE-CONSTRICTIVE HEMORRHAGIC PERICARDITIS FOLLOWING GROUP A STREPTOCOCCAL SEPTIC SHOCK IN A TEENAGE FEMALE

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Effusive-constrictive pericarditis (ECP) is an uncommon clinical syndrome where fluid fills the visceral pericardium, causing inflammation and fibrosis with constriction of the heart and potential for rapid progression to diastolic heart failure. We present a rare case of ECP following septic shock in an immunocompetent teenage patient. CASE PRESENTATION: A 16-year-old previously healthy female presented acutely with hypotension, tachycardia, and poor perfusion three days after falling in her shower. Computed tomography revealed bilateral pleural effusions and splenic and liver lacerations which were surgically managed. After initial recovery, she developed edema and tachycardia on POD 15, and quickly decompensated to ventricular fibrillation with return of spontaneous circulation after 15 minutes of cardiopulmonary resuscitation and defibrillation. Immediate bedside echocardiogram revealed a large pericardial effusion. A pericardial drain was placed and removed 150 mLs of sanguineous fluid. A gram stain and culture of the pericardial fluid were unrevealing. Sequential echocardiograms showed abnormal ventricular septal bounce during early diastole with overall decreased diastolic function. Cardiac MRI showed mild-to-moderate late gadolinium enhancement of the pericardium, a mildly depressed ejection fraction of 48.5%, and trace pericardial effusion. She was managed with intravenous immunoglobulin, empiric antibiotics, afterload reducing agents, and steroids. On POD 40, microbial cell-fee DNA returned positive for Streptococcus pyogenes, which had never grown out of previous blood cultures, and she was treated with penicillin G. DISCUSSION: We report a case of ECP in an immunocompetent teenage patient following S. pyogenes septic shock, complicated by chronic bilateral pleural effusions and hemopericardium with tamponade leading to cardiac arrest. In ECP, the pericardium becomes inelastic due to inflammation and fibrosis, impairing diastolic function.(1) Patients report feeling dyspneic or fatigued and can appear edematous. A hallmark of ECP is dissociation of intrathoracic and intracardiac pressures, with differential right and left ventricular early diastolic pressures and septal bounce on echocardiogram.(2) Pericardial fluid was culture-negative, though the patient was on broad spectrum antibiotics. Possibilities for the effusion include local antibody-mediated inflammatory response to antigens from an initial infection, or hematogenous spread. Criteria were not met for acute rheumatic heart disease CONCLUSIONS: Effusive-constrictive pericarditis following bacterial illness is a rare but life-threatening and rapidly progressive condition that presents non-specifically.(3) Early recognition with echocardiogram, prompt pericardiocentesis, and anti-inflammatory or steroidal therapy reduces need for surgical pericardiectomy and development of chronic constrictive pericarditis. Reference #1: Gentry, J., Klein, A. L., & Jellis, C. L. (2016). Transient Constrictive Pericarditis: Current Diagnostic and Therapeutic Strategies. Current Cardiology Reports, 18(5). doi: 10.1007/s11886-016-0720-2 Reference #2: Miranda, W. R., & Oh, J. K. (2017). Constrictive Pericarditis: A Practical Clinical Approach. Progress in Cardiovascular Diseases, 59(4), 369–379. doi: 10.1016/j.pcad.2016.12.008 Reference #3: Kim, K. H., Miranda, W. R., Sinak, L. J., Syed, F. F., Melduni, R. M., Espinosa, R. E., … Oh, J. K. (2018). Effusive-Constrictive Pericarditis After Pericardiocentesis. JACC: Cardiovascular Imaging, 11(4), 534–541. doi: 10.1016/j.jcmg.2017.06.017 DISCLOSURES: No relevant relationships by Danielle Levy, source=Web Response