RARE PRESENTATION OF ACUTE PURULENT PERICARDITIS AFTER MYOCARDIAL INFARCTION

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute onset pericarditis following a myocardial infarction (MI) is usually a benign, minimally symptomatic condition that occurs within 2-4 days of a MI. Purulent pericarditis is a rare diagnosis associated with primary infections such as pneumonia, meningitis or after an invasive thoracic procedure. Staphylococcus aureus and streptococcus pneumoniae are the most common etiologies. Rarely do these disease processes occur simultaneously. We present a case of a 58-year-old male with no preexisting condition or primary infection source with acute onset purulent pericarditis following a MI. CASE PRESENTATION: A 58-year-old male presented with substernal chest pain due to an inferior STEMI. He underwent left heart catheterization with percutaneous coronary intervention of the right coronary artery (RCA) and stent placement for 100% stenosis. Transthoracic echocardiogram showed severe left and right ventricular systolic dysfunction with a physiologic posterior pericardial effusion. CT chest showed a thickened anterior pericardium. On day 2, the patient developed atrial fibrillation. Catheterization showed a patent stent with 70% distal stenosis of the RCA. An intra-aortic balloon pump (IABP) was placed. He became febrile, so blood and urine cultures were drawn. On day 3, the Afib returned with two failed attempts of cardioversion. On day 4, the patient had chest pain, elevated troponins, fever, and leukocytosis. He underwent an urgent CABG due to concerns for reinfarction with active ischemia. Intraoperative transesophageal echocardiogram showed no signs of pericardial effusion. When the pericardium was entered, 200mL of purulent fluid was expelled. A fluid culture was sent for analysis. Previously drawn blood and urine cultures grew staph aureus suggesting hematogenous seeding from a week-old infection. Ancef was started for MSSA coverage. The patient responded to the antibiotic and was afebrile for the remaining hospital course. Culture of the purulent fluid was negative - it contained a significant number of neutrophils indicating acute pericarditis but is inconclusive for a definitive diagnosis. DISCUSSION: Majority of studied purulent pericarditis cases are discovered postmortem due to late presentation and high mortality rate. Patients who have myocardial infarctions with bacteremia should be monitored for pericardial effusions and treated with the appropriate antimicrobial coverage to prevent purulent pericarditis. CONCLUSIONS: We suspect the post MI pericardial effusion was seeded by staph aureus resulting in the purulent pericarditis, though the origin of the staph aureus bacteremia remains unclear. If the patient would not have re-infarcted, we predict the infection would have progressed and caused systemic collapse from fulminant purulent pericarditis. Reference #1: 1. Likoff, William. “Pericarditis Complicating Myocardial Infarction.” The American Journal of Cardiology, vol. 7, no. 1, 1961, pp. 69–72., doi:10.1016/0002-9149(61)90424-6. Reference #2: 2. Anvari, Maryam Sotoudeh, et al. “Bacterial Pericarditis and Antimicrobial Resistance at the Tehran Heart Center, Iran.” The Journal of Infection in Developing Countries, vol. 9, no. 07, 2015, pp. 780–784., doi:10.3855/jidc.6027. Reference #3: 3. Rubin, Robert H., and Robert C. Moellering. “Clinical, Microbiologic and Therapeutic Aspects of Purulent Pericarditis.” The American Journal of Medicine, vol. 59, no. 1, 1975, pp. 68–78., doi:10.1016/0002-9343(75)90323-x. DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response No relevant relationships by KYLIE DICKMAN, source=Web Response