EFFUSIVE CONSTRICTIVE PERICARDITIS: AN UNUSUAL COMPLICATION OF PNEUMOCOCCAL PNEUMONIA

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumococcal pericarditis secondary to pneumococcal pneumonia is a rare entity usually seen in patients with significant co-morbidities. We present a case of invasive pneumococcal infection with recurrent pericardial effusion and constrictive pericarditis in a relatively healthy male. CASE PRESENTATION: 55 years old male with no significant past medical history presented with complaints of progressively worsening chest pain and shortness of breath from 1 week. Vital signs were evident for HR of 117, RR of 35, O2 saturation 89%, fever of 100.8F. BP was normal. Physical exam was positive for crackles on right lung field. Labs were positive for bandemia. Imaging showed right lobar infiltrates with bilateral pleural effusions. Blood and pleural fluid culture were positive for streptococcus pneumoniae. Patient was started on IV ceftriaxone for pneumococcal sepsis. Patient continued to be dyspneic despite on treatment. Echocardiogram showed pericardial effusion. Pericardiocentesis was done draining purulent fluid. Patient had recurrence despite pericardiocentesis, requiring a subxiphoid pericardial window. Patient’s condition improved and he was discharged on anti-inflammatory and iv antibiotics. Patient was re-admitted 1 month later with worsening dyspnea. Echocardiogram showed recurrence of pericardial effusion with thickened pericardium suggestive of constrictive pericarditis. Cardiac catheterization further confirmed the diagnosis. Patient was referred for pericardiectomy. During procedure, thickened pericardium with dense adhesions and caseous material was seen in the pericardial space warranting complete pericardiectomy. Patient showed significant improvement post procedure. DISCUSSION: Streptococcus pneumonia is the most common form of community acquired pneumonia. Primarily presenting as lobar consolidation, it can have local complications like pleural effusion as well as systemic invasion. Overall incidence of invasive pneumococcal disease in the US has significantly declined after the widespread use of pneumococcal conjugate vaccination. Purulent pericarditis is a rare entity occurring secondary to hematogenous or intrathoracic spread. Diagnosis is established with pericardial fluid culture and microscopy. Treatment option includes pericardial drainage along with IV antimicrobial therapy. Treatment is continued till clinical improvement which usually takes 2-4 weeks. Any form of purulent pericarditis has a mortality risk of 20-30% with chances of complicating constrictive pericarditis in atleast 3-5% of cases. CONCLUSIONS: Invasive pneumococcal infection is less commonly seen in the modern era of vaccination. Purulent pericarditis is one of its rare complication and can subsequently be complicated by constrictive pericarditis which has a high rate of mortality. High index of suspicion for diagnosis and immediate intervention is thus required. Reference #1: Sauleda et al, M.D.Effusive–Constrictive Pericarditis.January 29, 2004 N Engl J Med 2004; 350:469-475 DOI: 10.1056/NEJMoa035630 Reference #2: Syed et al.Effusive-constrictive Pericarditis.Heart Fail Rev. 2013 May;18(3):277-87. doi: 10.1007/s10741-012-9308-0. Reference #3: William Miranda MD.Effusive-Constrictive Pericarditis: Maybe Not as Rare and as Bad as We Thought. ACC 4/08/2019 DISCLOSURES: No relevant relationships by Muhammad Aamir, source=Web Response No relevant relationships by Adil Cheema, source=Web Response No relevant relationships by Luna Khanal, source=Web Response No relevant relationships by Sugandhi Mahajan, source=Web Response No relevant relationships by Adarsha Ojha, source=Web Response