BACTERIAL PERICARDITIS: AN ODD PRESENTATION OF OBSTRUCTIVE/DISTRIBUTIVE SHOCK

Abstract

SESSION TITLE: Case Report Semifinalists 6 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pericarditis represents a small portion of ED chest pain visits (5%) and an even smaller portion of hospital admissions, 0.1%. Depending on the etiology, the prognosis and outcome differ significantly. Purulent pericarditis is an exceedingly rare occurrence (less than 1% of cases of pericarditis) and falls into a high mortality, high-risk group. Here we present a case of rapidly progressive bacterial pericarditis causing cardiac tamponade and shock CASE PRESENTATION: A 58-year old African American male presented to the emergency department with one day of tight radiating chest pain that was relieved with leaning forward. An EKG showed diffuse ST elevations indicative of pericarditis. At this time, there were no systemic signs of infection. NSAIDs and colchicine were started for presumed viral pericarditis. Serum troponins were mildly elevated. An echocardiogram (echo) showed decreased ejection fraction but no pericardial effusion. The patient underwent left and right heart catheterization showing volume overload but no evidence of coronary artery disease. Diuretics were started, but within hours his urine output dropped and he became hypotensive. He was intubated for respiratory failure. His lactate and procalcitonin levels were increased, but without leukocytosis. The patient was started on broad-spectrum antibiotics. Blood cultures grew streptococcus within 24 hours. A bedside ultrasound showed interim development of a large pericardial effusion and possible tamponade physiology. A formal repeat echocardiogram confirmed this finding. The patient underwent emergency pericardiocentesis and pericardial drain placement under fluoroscopy yielding 200cc of purulent pericardial fluid. The patient rapidly deteriorated, expiring less than 48 hours from admission. DISCUSSION: This patient had a very low clinical suspicion for bacterial pericarditis upon initial presentation. He had no evidence of a pericardial effusion on his first echocardiogram. However, his clinical condition rapidly deteriorated due to development of purulent pericardial effusion and cardiac tamponade that was detected on point of care chest ultrasound. The patient underwent pericardial drainage and was started on broad-spectrum antibiotics. Bacterial pericarditis is a rare medical condition with purulent pericardial effusion with cardiac tamponade is a rare medical condition with high mortality. CONCLUSIONS: There are two critical points in this case: first, distributive and obstructive shock can coexist in some cases. Obstructive shock is one of the least frequent causes of shock, especially in the setting of bacteremia and when clinicians gravitate to distributive shock as a primary etiology. Second, bedside ultrasound is a powerful tool that can change quickly management if used wisely. Reference #1: Adler Y et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). The European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, Volume 36, Issue 42, 7 November 2015, Pages 2921–2964, https://doi.org/10.1093/eurheartj/ehv318. Reference #2: Bhaduri-McIntosh, S et al. Purulent Pericarditis Caused by Group A Streptococcus. Tex Heart Inst J. 2006; 33(4): 519–522. Reference #3: Sagristà-Sauleda, J et al. Diagnosis and management of pericardial effusion. World J Cardiol. 2011 May 26; 3(5): 135–143. Published online 2011 May 26. https://doi.org/10.4330/wjc.v3.i5.135 DISCLOSURES: No relevant relationships by Juan Galvis, source=Web Response No relevant relationships by Umair Gauhar, source=Web Response No relevant relationships by Saarik Gupta, source=Web Response