Primary meningococcal pericarditis presenting as acute coronary syndrome with angiographically confirmed obstructive lesions

Abstract

Background: Primary meningococcal pericarditis (PMP) is defined as purulent pericarditis without clinical evidence of meningococcaemia, meningitis, or other foci of meningococcal infection. Meningococcal infections associated with ST segment elevation and raised cardiac enzymes mimicking acute myocardial infarction have been previously reported, but all of these cases had a normal coronary angiogram, which may indeed represent a diagnosis of myocarditis, especially when no endomyocardial biopsies had been conducted. We report a unique case of primary meningococcal pericarditis presenting as acute coronary syndrome with angiographically confirmed obstructive lesions. Case Description: A 68 y old gentleman, an ex-smoker with multiple comorbidities, presented with acute-onset chest pain. There was no fever, skin rashes or meningeal signs. Electrocardiogram revealed hyperacute T at leads V2 to V5 and ST elevation at leads V7 to V9. Bedside echocardiogram disclosed septal wall hypokinesia with a pericardial effusion. Cardiac catheterisation revealed triple-vessel disease with critical stenosing lesion in the mid left anterior descending artery. Plasma troponin I was elevated. 3 d later, patient developed new-onset fever with worsening pericardial effusion and signs of impending cardiac tamponade. Emergent pericardiocentesis yielded pericardial fluid with an exudative picture. Both pericardial fluid and blood culture grew Neisseria meningitidis W-135. Intravenous ceftriaxone 2 g 12 h was initiated. Post-exposure prophylaxis was given to all healthcare workers affected. In spite of appropriate antimicrobial therapy, patient further deteriorated and succumbed due to multiorgan failure. Discussion: Invasive meningococcal infections other than meningitis and meningococcaemia have not been reported in Malaysia before. Neisseria meningitidis W-135 infections in Malaysia are commonly associated with Hajj pilgrimage. PMP usually has a favourable outcome with appropriate and timely antimicrobial administration. However, it was not suspected initially in our case who had no infectious prodrome, history of Hajj pilgrimage or exposure to a known case of meningococcal infection. The infectious process probably acted as an inciting event for acute coronary syndrome secondary to increased coronary vascular resistance induced by inflammatory cytokines. Conclusion: Our case underscores the importance to include infective causes of pericarditis in the differential diagnosis of pericardial effusion in any patient presenting with acute coronary syndrome, especially high-risk groups such as elderly population, diabetics, and those with multiple comorbidities.