Primary Meningococcal Pericarditis Research Articles

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

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.

RAPIDLY PROGRESSIVE CARDIAC TAMPONADE AND BILATERAL PLEURAL EFFUSIONS IN THE SETTING OF MENINGOCOCCEMIA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary meningococcal pericarditis (PMP) is a rare form of purulent pericarditis that can occur in the event of N. Meningitidis bacteremia without meningitis or fulminant septicemia. This form of pericarditis can be infectious or immunologic and in either form, can cause life threatening tamponade (1). Here described is a case of rapidly evolving purulent pericarditis and pleural effusion in a patient with meningococcal bacteremia. CASE PRESENTATION: A 56 year old male with a history of HIV, and remote bacterial meningitis presented with pleuritic chest pain, worsened in the supine position, fevers, and diaphoresis. At the initial time of presentation ECG findings were consistent with pericarditis and bedside echo showed minimal pericardial effusion. The patient was evaluated and due to persistent hypotension, was admitted to the MICU. Hours after admission, the patient developed worsened chest pain, in the setting of continued hypotension. A bedside echo and CTPE showed increasing pericardial effusion with tamponade physiology, as well as small developing pleural effusions. Urgent pericardiocentesis was performed, 350mL of purulent fluid was obtained and a pericardial drain placed. Pericardial fluid cultures were negative, but blood cultures grew Neisseria meningitidis. Antibiotics were deescalated from piperacillin-tazobactam to ceftriaxone at that time. Serial bedside ultrasounds and showed a on hospital day three showed rapidly increasing pleural effusions despite pericardial drain placement. A right sided diagnostic thoracentesis was performed that was exudative by Lights Criteria and class 2 with a pH 7.45 and glucose 177. The following day, left sided thoracentesis was performed, and the patient had improvement in his hypoxia and symptomatology. He was discharged home to complete a 14 day course of ceftriaxone. DISCUSSION: The most common forms of invasive meningococcal disease are septicemia and meningitis. Approximately 10% of the population is a carrier of N. menigitidis, but invasive disease is relatively rare (2). Other sites of involvement are less common, but pericarditis has been reported in meningococcal bacteremia. This most often occurs in the presence of meningococcal meningitis or fulminant septicemia (3). This patient had no signs of meningitis or fulminant sepsis at the time of presentation. Rapid accumulation of purulent fluid causing cardiac tamponade has been described in PMP (4). CONCLUSIONS: Primary meningococcal pericarditis is a remarkably unusual presentation of meningococcal disease. Rapid progression to tamponade physiology can develop in these patients and monitoring for signs of pericarditis in patients with meningococcal disease should be implemented. Reference #1: Pericarditis as a complication of meningococcal meningitis. Morse JR, Oretsky MI, Hudson JA, Ann Intern Med. 1971;74(2):212. Reference #2: Update on meningococcal disease with emphasis on pathogenesis and clinical management. van Deuren M, Brandtzaeg P, van der Meer JW. Clin Microbiol Rev. 2000 Jan; 13(1):144-66. Reference #3: Zeidan A, Tariq S, Faltas B, Urban M, McGrody K. A case of primary meningococcal pericarditis caused by Neisseria meningitidis serotype Y with rapid evolution into cardiac tamponade. J Gen Intern Med. 2008;23(9):1532–1535. DISCLOSURES: No relevant relationships by Giovi Grasso-Knight, source=Web Response No relevant relationships by Matthew Schloop, source=Web Response No relevant relationships by Mouhamed Shatila, source=Web Response

Invasive meningococcal disease with pericarditis and pneumonia: A rare presentation in childhood

Previously healthy 2-year-old boy presented with a 3-day history of fever, irritability and vomiting. There was no cutaneous rash. Ceftriaxone (100 mg/kg/day) and Dexamethasone 5.5 mg 6/6 h (on the first 3 days) were started and lumbar puncture was performed. Cerebral spinal fluid (CSF) showed 3.696 WBCs/μL with 99% neutrophils, glucose 1 mg/dL and total protein 578.0 mg/dL. CSF Gram stain showed extracellular and intracellular Gram-negative diplococci. Latex agglutination was reactive for N. meningitidis group C. The CSF culture was negative. After 6-day of antibiotic treatment patient started with dyspnea, dry cough and hypotension. Cardiorespiratory examination revealed an elevated jugular venous pressure, normal heart sounds, with no pericardial rub, coarse sounds with crackles over left base were heard. New CSF analyses showed 336 WBCs/μL with 61% neutrophils, 39% lymphocytes, protein 99.5 g/L and glucose 26 mg/dL (serum glucose 75 mg/dL). The CSF and blood cultures were negative. Chest X-ray showed an enlarged cardiac silhouette, consolidation in the left lung and pleural effusion. The antimicrobial treatment was changed to meropenem. Computed tomography of the chest showed moderate pleural effusion, consolidation in the left lobe. The cardiac echography revealed a pericardial effusion. There was no sign of imminent cardiac tamponade. Pericardiocentesis was performed and a total of 115 ml hemorrhagic pericardial fluid was aspirated. The fluid analysis demonstrated 1.460 WBC/mm3, with 85% polymorphonuclear neutrophils and 15% lymphocytes, total proteins of 4.5 g/dL, 836 U/L LDH and glucose 60 mg/dL. No microorganism was observed by Gram and Ziehl-Nielsen stain. The pericardial fluid culture to aerobic and mycobacteria was negative. Methylprednisolone was administered for five days. Patient was discharged after 14 days of antibiotic therapy with full recovery. We present a case of meningococcal meningitis that developed two rare manifestations associated in children: pericarditis and pneumonia (Fig. 1, Fig. 2, Fig. 3). Occurrence of cardiac tamponade in reactive pericarditis is most often associated in serogroup C infections [1], [2], serogroup predominant in Amazon [3]. Meningococcal pneumonia is more associated with serogroup Y [4]. The forms of presentation of pericardial involvement include: disseminated meningococcal infection with pericardial, primary meningococcal pericarditis and reactive meningococcal pericarditis [1]. The hypersensitivity reaction type 3 tends to occur during the convalescent period (4–10 days after the start of antibiotic therapy) [5]. Thought to be due to a hypersensitivity reaction to previously damaged pericardial tissue, which acts as an antigen stimulus to antibody formation [5]. If the effusion is large treatment is done with high doses corticoids [1]. Fig. 1 Chest X-ray showed an enlarged cardiac silhouette, consolidation in the inferior lobe of left lung and pleural effusion. Fig. 2 Computed tomography of the chest (CTC) showed left lung atelectasis, moderate pleural effusion and consolidation in the left upper lobe. CTC mediastinal window shows moderate pericardial effusion. Fig. 3 The cardiac echography revealed a pericardial effusion. There was no sign of cardiac tamponade.

A Case of Primary Meningococcal Pericarditis Caused by Neisseria Meningitidis Serotype Y with Rapid Evolution into Cardiac Tamponade

Primary meningococcal pericarditis (PMP) is a rare form of acute purulent pericarditis that often evolves into cardiac tamponade and usually requires pericardial drainage. PMP is a rare, difficult to diagnose, rapidly progressive form of meningococcal infections. PMP is typically caused by Neisseria meningitidis of serotype C, or, less commonly, B or W135. We report the second case of PMP caused by Neisseria meningitidis of serotype Y. Our patient was not critically ill at presentation, and her presentation could have been consistent with viral uncomplicated pericarditis with the exception of the mild leukocytosis with a left shift in the differential. Clinicians should be aware that early in the course of PMP, the illness may not be severe. Mild leukocytosis with a left shift or bandemia in the setting of what otherwise seems to be a case of uncomplicated viral pericarditis should prompt suspicion for PMP and further evaluation and/or monitoring.

Cardiac Tamponade as a Delayed Presentation of Neisseria meningitidis Infection in a 5-Month-Old Infant

This is a case of a 5-month-old female infant diagnosed with primary meningococcal pericarditis. Pericarditis is a well-recognized but uncommon complication of meningococcal infection. Primary meningococcal pericarditis, defined as purulent pericarditis without any clinical evidence of disseminated meningococcemia, meningitis, or other foci of meningococcal infection, is exceedingly rare, with only 21 reported cases since the first case was reported in 1939. This case report of primary meningococcal pericarditis is the youngest case and only the second case reported in an infant in the English literature to date.

Primary Meningococcal Pericarditis

Primary meningococcal pericarditis (PMP) is a purulent pericarditis that can rapidly progress to complications, including cardiac tamponade, pericardial constriction, and need for surgical intervention. Risk factors associated with such complications are not well characterized. We describe a case of PMP and analyze all reported cases of PMP to determine whether certain risk factors lead to the development of cardiac tamponade, pericardial constriction, and need for surgical intervention. Twenty-six cases of PMP were identified, of which 23 (88%) developed tamponade, 7 (27%) constriction, and 7 (27%) need for surgical intervention. A positive pericardial fluid culture was associated with the development of tamponade, whereas a delay in antibiotic initiation, more than 24 hours after chest pain onset, was associated with development of constriction and the need for surgical intervention. All cases of constriction required surgical intervention. Early antibiotic administration appears to protect against the development of constriction and subsequent need for surgery.

Severe meningococcal disease in childhood

Severe meningococcal disease in childhood

Pericarditis meningocócica primaria por serogrupo C

We report the case of a 15-year-old female, with no previous medical history, who presented cardiac tamponade secondary to purulent pericarditis caused by Neisseria meningitidis serogroup C. This microorganism is the etiologic agent in 6-16% of the cases of purulent pericarditis, most in association with previous or concomitant central nervous system involvement (meningitis). Exceptionally, as in this case, the pericarditis is not accompanied by meningitis (Primary Meningococcal Pericarditis). The patient was treated with antibiotics, pericardiocentesis and steroids with excellent response. It is important to point out that meningococcal disease may present in unusual forms which may lead to diagnostic and therapeutics difficulties.

Primary meningococcal pericarditis complicated by tamponade

AbstractPericarditis as a complication of meningococcal meningitis or meningococcaemia is uncommon, occurring in approximately 5.1% of cases. Meningococcal infection of the pericardium in the absence of meningitis is even rarer, with only 22 cases previously described. We report a case of primary meningococcal pericarditis complicated by cardiac tamponade in a 27 year old male and review all previously reported cases. The clinical features, epidemiology, investigations and management of primary meningococcal pericarditis are discussed.

Primary meningococcal pericarditis with cardiac tamponade in an infant

Primary meningococcal pericarditis with cardiac tamponade in an infant

Primary meningococcal pericarditis in a pregnant woman

Pericardial effusion is an unusual complication of meningitis due to Neisseria meningitidis. Primary meningococcal pericarditis without signs of meningitis is rare. Only 18 cases have been described in the literature. The first case was reported in 1939 and the others since 1971. We report a case of primary meningococcal pericarditis in a pregnant woman. Improvement followed prompt antibiotic therapy. Fetal death necessitated abortion by curettage.

Pathophysiology of primary meningococcal pericarditis associated with Neisseria meningitidis group C. a case report and review of the literature

Pericarditis associated with Neisseria meningitidis in the absence of meningitis or meningococcemia is an extremely rare event. We report herein a case of a 59-yr-old woman with primary meningococcal pericarditis caused by Neisseria meningitidis group C. The patient responded to a course of penicillin therapy and recovery was uncomplicated. The pathophysiologic features underlying or contributing to the disease are discussed and the pertinent literature is reviewed.

Primary meningococcal pericarditis. Diagnosis by counter-current immunoelectrophoresis

PURULENT pericarditis is an uncommon disorder that often escapes clinical detection despite its lifethreatening nature.1Appropriate management requires vigorous antimicrobial therapy and, in most cases, surgical drainage. Identification of the responsible pathogen is of paramount importance. We report a patient with pericardial tamponade who was found to have primary meningococcal pericarditis. The diagnosis was suggested by the Gram stain of the pericardial fluid, but, because the patient had recently been given antibiotics, cultures were negative. A new technique, counter-current immunoelectrophoresis (CIE), was used to confirm the etiologic diagnosis. This is, to our knowledge, the first time CIE has been used successfully in the diagnosis of purulent pericarditis. Report of a Case A 49-year-old mother of four was in excellent health until 10:45 AM on Aug 1, 1974, when she experienced an abrupt rigor followed promptly by fever and diffuse myalgia. She remained bedridden for 48 hours, with fever, sweats,

Primary Meningococcal Pericarditis Presenting with Tamponade

An unusual case of a patient with primary meningococcal pericarditis presenting with tamponade is reported. tdespite repeated aspiration and appropriate antibiotic therapy with eradication of group C Neisseria meningitidis, pericardial effusion continued to reaccumulate. Institution of high-dosage corticosteroid therapy resulted in rapid resolution of the effusion. Only six other cases of primary meningococcal pericarditis have been reported in the English literature. Early manifestations of this disease are due to bacterial invasion of the pericardium. The later phase of intensive reaccumulation of sterile pericardial fluid may conceivably be related to meningococcal endotoxin and appears to be responsive to corticosteroid or salicylate therapy. Recognition of this phenomenon may obviate the necessity for a pericardiectomy.