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Staphylococcus aureus pericardial abscess in a patient with liver cirrhosis: case report.

Abstract: Pericardial abscess is a rare complication of Staphylococcus aureus bacteremia. We report the case of a 40-year-old man with hepatitis C and liver cirrhosis who presented with high-grade fever and chest pain. Transthoracic echocardiography showed a pericardial mass and computed tomographic scanning and transcsophageal echocardiography confirmed the presence of a loculated fluid collection. His illness persisted despite IV antibiotics and video-assisted thoracoscopic drainage. The patient was cured after surgical drainage and pericardiectomy.

Key Words: liver cirrhosis, pericardial abscess, Staphylococcus aureus

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Purulent pericarditis is a well-known although rare complication of Staphylococcus aureus infection in modern practice. Purulent pericarditis can result from hematogenous spread, direct extension from pneumonia, empyema, chest trauma, or postoperative mediastinitis. A localized discrete pericardial abscess, in contrast, is a rare and unusual complication of staphylococcemia. We are aware of only two case reports in the English language literature about a pericardial abscess as a complication of S. aureus bacteremia. (1,2)

Case Report

A 40-year-old man with hepatitis C and Child-Pugh Class A liver cirrhosis developed fever, dry cough, and myalgias l week after undergoing a screening colonoscopy. Initial evaluation at his local hospital revealed a normal chest radiograph. Two sets of blood cultures grew methicillin-sensitive S. aureus (MSSA). He received a 10-day course of therapy with oral levofloxacin. Thereafter his fever resolved and his symptoms improved.

Ten days after completing the course of levofloxacin therapy, he again developed high-grade fever (38.9[degrees]C) and dry cough, in addition to dyspnea and left-sided chest pain radiating to the left shoulder. These symptoms led to his admission to a local hospital. A chest radiograph showed cardiomegaly and a transthoracic echocardiogram revealed a "pericardial mass." He was transferred to our hospital, where physical examination showed fever (39[degrees]C), normal blood pressure (125/65 mm Hg), no jugular vein distention, and no friction rub or murmur. His white blood cell count was 15,000/[mm.sup.3], with 88% neutrophils. His erythroeyte sedimentation rate was 111 mm/h. Blood cultures again grew MSSA. An electrocardiogram showed normal sinus rhythm with no ST-segment abnormalities. A chest radiograph showed cardiomegaly and a small left pleural effusion. A transthoracic echocardiogram (Fig. 1) followed by a transesophageal echocardiogram demonstrated a loculated fluid collection in the posterolateral wall of the pericardium with no evidence of valvular vegetations. A computed tomographic (CT) scan of the chest confirmed the presence of a 5 x 10 x 8-cm left posterolateral pericardial fluid collection.

[FIGURE 1 OMITTED]

Despite treatment with IV vancomycin and then cefazolin, the patient's fever and leukocytosis persisted. Video-assisted thoracoscopic surgical drainage yielded 200 ml of purulent fluid from the pericardial collection of fluid; cultures grew MSSA. Despite this intervention, fever and leukocytosis continued. Three days after drainage, a repeat CT scan of the chest showed persistence of the pericardial fluid collection. Because it appeared that he had not improved either clinically or by imaging from the localized infection, pericardiectomy was performed with ultimate drainage of a collection of pus located between the right atrium and the aorta. Pathologic examination of the wall of the pericardial abscess showed focally suppurative acute and chronic pericarditis. Clusters of gram-positive cocci were noticed within the pericardial tissue. After pericardiectomy, the patient's fever resolved and the white blood cell count normalized. He was treated with IV cefazolin for 2 additional weeks. After 10 weeks of follow-up, he remained afebrile and without further symptoms.

Discussion

Pericardial infection usually manifests as diffuse inflammation of the pericardium with the accumulation of pus within the pericardial space. Loculation of pericardial infection in the form of an abscess is rare. S. aureus accounts for approximately one-fourth of cases of purulent pericarditis. (3) However, we found only two reported cases in the English-language literature of pericardial abscesses attributable to S. aureus.

The mechanism by which S. aureus causes a focal abscess in the pericardium is unknown. Possible explanations include hematogenous seeding or direct extension into a preexisting pericardial cyst or localized purulent pericarditis occurring in a patient with old pericardial adhesions. We cannot explain the pathogenesis of our patient's inflection, lie had no obvious reason to have pericardial adhesions such as a history of cardiac surgery or pericarditis and there was no evidence for a pericardial cyst on pathologic examination of the pericardium. His history of cirrhosis may have predisposed him to S. aureus bacteremia.

Our case illustrates four important points. First, diagnosis of a localized pericardial abscess is relatively easy if echocardiography or CT scanning is used. Second, video-assisted thoracoscopic surgery drainage failed to cure our patient; pericardiectomy and open drainage were necessary to adequately drain our patient's abscess. Third, our patient had a purulent pericardial infection yet had no symptoms or signs of pericardial infection, by history or clinical examination, resembling acute pericarditis or pericardial tamponade. Fourth, this case emphasizes the potential pitfalls of treating S. aureus bacteremia with short courses of antistaphylococcal therapy without searching for a source of the infection using echocardiography.

Key Points

* Pericardial abscess is a rare complication of Staphylococcus aureus bacteremia.

* Diagnosis of a localized pericardial abscess is relatively easy if echocardiography or computed tomographic scanning is used.

* Pericardiectomy and open drainage may be required to adequately treat a pericardial abscess.

References

(1.) Nwiloh JO, Egbe PA, Tagoe AT, et al. Staphylococcus aureus pericarditis masquerading as anterior mediastinal mass: Mediastinal mass from pericarditis. Chest 2000:118:1832-1833.

(2.) Suzuki S, Tajimi T, Takeshita A, et al. Isolated right heart purulent pericarditis forming a large mediastinal mass. Chest 1988;93:667-668.

(3.) Klacsmann PG. Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis: An 86 year autopsy experience in 200 patients. Am J Med 1977:63:666-673.

From the Department of Medicine, Duke University Medical Center, Durham, NC.

Reprint requests to Fadi El-Ahdab, MD, Department of Medicine, Duke University Medical Center, P.O. Box 31055, Durham, NC 27710. Email: elahd001@mc.duke.edu

Accepted February 25, 2003,
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Title Annotation:Case Report
Author:Bashore, Thomas
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Sep 1, 2003
Words:980
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