A RARE CAUSE OF MULTIFOCAL PNEUMONIA AND CONSTRICTIVE PERICARDITIS: COXSACKIEVIRUS A

Abstract

SESSION TITLE: Cardiovascular Chest Infection Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: In developed countries, acute pericarditis is usually caused by viral infection with coxsackie B virus being the most common cause. We report a case of 30-year-old man who presented with multifocal pneumonia and subsequently developed constrictive pericarditis due to Coxsackievirus A.CASE PRESENTATION: A 30-year-old man without medical history was seen in Emergency Department(ED) for fever, cough and dyspnea and discharged with 5-day course of Azithromycin for community acquired pneumonia. 10 days later he returned with CT-Chest showing bilateral basal opacities, small bilateral(b/l) pleural effusions. He had temperature of 101.2 Fahrenheit, heart rate >100 beats per minute and oxygen saturation of 88% on room air. Electrocardiogram: sinus tachycardia, troponin negative. Repeat CT: moderate pleural effusions, b/l lower lobe infiltrates and 1.5cm thick heterogeneous pericardial effusion. He was started on intravenous(IV) Ceftriaxone and doxycycline. Pleural fluid analysis showed exudative effusion. Right heart catheterization(RHC): constrictive physiology. Left-sided VATS showed inflammatory adhesions, 800 mL serous fluid drained via chest tube. Open pericardial window revealed minimal effusion and inflamed pericardium with significant adhesions between heart and pericardium which were broken digitally. Labs: mildly elevated antibody titers of Coxsackievirus A-7, A-9, A-16 and A-24. Infectious, rheumatologic and autoimmune work up, including pleural, pericardial fluid and blood culture were negative. He was started on high dose steroids. Biopsy showed acute and chronic pericarditis. He improved and was discharged with cardiology and rheumatology follow-up.DISCUSSION: Coxsackievirus A usually affects skin and mucous membranes whereas Coxsackievirus B affects heart, lungs, pancreas and liver and is the most common cause of myocarditis and pericarditis in adults. It has been identified in up to 50% of viral cardiac cases. Our case is unique as Coxsakivirus A has rarely been reported as cause of lower respiratory tract infections or myopericarditis. Acute pericarditis can present as pleuritic chest pain and dyspnea. Patients with an infectious etiology may present with signs and symptoms of systemic infection such as fever and leukocytosis. Our patient had fever, cough, pleuritic chest pain and leukocytosis. Treatment of idiopathic and viral pericarditis includes combination therapy with colchicine and NSAID. Glucocorticoids are used in patients with contraindication to NSAIDs or specific indication like inflammatory disease. Our patient was initially treated with Colchicine and ibuprofen. He was also briefly treated with high dose IV steroids for constrictive pericarditis and was discharged on steroid tapering regimen.CONCLUSIONS: We highlight a rare case of multifocal pneumonia and constrictive pericarditis caused by coxsackievirus A. It also sheds light on diagnostic and treatment approach.Reference #1: Saikia UN, Mishra B, Sharma M, Nada R, Radotra B. Disseminated coxsackievirus B fulminant myocarditis in an immunosuppressed adult: a case report. Diagn Microbiol Infect Dis. 2014;78:98–100. doi: 10.1016/j.diagmicrobio.2013.07.011.Reference #2: Liapounova NA, Mouquet F, Ennezat PV. Acute myocardial infarction spurred by myopericarditis in a young female patient: Coxsackie B2 to blame. Acta Cardiol. 2011;66:79–81.Reference #3: Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:76.DISCLOSURES: No relevant relationships by Moses BachanNo relevant relationships by Salma KhanNo relevant relationships by Zinobia KhanNo relevant relationships by Sonam NihalaniNo relevant relationships by Ambreen Shahzadi SESSION TITLE: Cardiovascular Chest Infection Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: In developed countries, acute pericarditis is usually caused by viral infection with coxsackie B virus being the most common cause. We report a case of 30-year-old man who presented with multifocal pneumonia and subsequently developed constrictive pericarditis due to Coxsackievirus A. CASE PRESENTATION: A 30-year-old man without medical history was seen in Emergency Department(ED) for fever, cough and dyspnea and discharged with 5-day course of Azithromycin for community acquired pneumonia. 10 days later he returned with CT-Chest showing bilateral basal opacities, small bilateral(b/l) pleural effusions. He had temperature of 101.2 Fahrenheit, heart rate >100 beats per minute and oxygen saturation of 88% on room air. Electrocardiogram: sinus tachycardia, troponin negative. Repeat CT: moderate pleural effusions, b/l lower lobe infiltrates and 1.5cm thick heterogeneous pericardial effusion. He was started on intravenous(IV) Ceftriaxone and doxycycline. Pleural fluid analysis showed exudative effusion. Right heart catheterization(RHC): constrictive physiology. Left-sided VATS showed inflammatory adhesions, 800 mL serous fluid drained via chest tube. Open pericardial window revealed minimal effusion and inflamed pericardium with significant adhesions between heart and pericardium which were broken digitally. Labs: mildly elevated antibody titers of Coxsackievirus A-7, A-9, A-16 and A-24. Infectious, rheumatologic and autoimmune work up, including pleural, pericardial fluid and blood culture were negative. He was started on high dose steroids. Biopsy showed acute and chronic pericarditis. He improved and was discharged with cardiology and rheumatology follow-up. DISCUSSION: Coxsackievirus A usually affects skin and mucous membranes whereas Coxsackievirus B affects heart, lungs, pancreas and liver and is the most common cause of myocarditis and pericarditis in adults. It has been identified in up to 50% of viral cardiac cases. Our case is unique as Coxsakivirus A has rarely been reported as cause of lower respiratory tract infections or myopericarditis. Acute pericarditis can present as pleuritic chest pain and dyspnea. Patients with an infectious etiology may present with signs and symptoms of systemic infection such as fever and leukocytosis. Our patient had fever, cough, pleuritic chest pain and leukocytosis. Treatment of idiopathic and viral pericarditis includes combination therapy with colchicine and NSAID. Glucocorticoids are used in patients with contraindication to NSAIDs or specific indication like inflammatory disease. Our patient was initially treated with Colchicine and ibuprofen. He was also briefly treated with high dose IV steroids for constrictive pericarditis and was discharged on steroid tapering regimen. CONCLUSIONS: We highlight a rare case of multifocal pneumonia and constrictive pericarditis caused by coxsackievirus A. It also sheds light on diagnostic and treatment approach. Reference #1: Saikia UN, Mishra B, Sharma M, Nada R, Radotra B. Disseminated coxsackievirus B fulminant myocarditis in an immunosuppressed adult: a case report. Diagn Microbiol Infect Dis. 2014;78:98–100. doi: 10.1016/j.diagmicrobio.2013.07.011. Reference #2: Liapounova NA, Mouquet F, Ennezat PV. Acute myocardial infarction spurred by myopericarditis in a young female patient: Coxsackie B2 to blame. Acta Cardiol. 2011;66:79–81. Reference #3: Chiabrando JG, Bonaventura A, Vecchié A, et al. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:76. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Salma Khan No relevant relationships by Zinobia Khan No relevant relationships by Sonam Nihalani No relevant relationships by Ambreen Shahzadi