SPC365

Purulent Pericarditis Complicating Staphylococcus Aureus Bacteremia: A Golden Challenge

Session: Casos Clínicos: Doença Valvular, Pericárdica, Pulmonar, Congénita e Miocardiopatias
Speaker: Luís Miguel de Sousa Azevedo

Congress: CPC 2024
Topic: F. Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Theme: ---
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Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Luís Sousa Azevedo; Catarina Ribeiro Carvalho; Marta Bernardo; Isabel Martins Moreira; Isabel Nobrega Fernandes; Sara Borges; Miguel Moz; Silvia Leão; Ilídio Moreira

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">A 58-year-old man presented to the Emergency Department (ED) with right shoulder pain. In his medical history he only had hypertension. A week before, he experienced mechanical shoulder pain after exertion, and attempted self-treatment with intramuscular diclofenac administered by a non-medical friend, without improvement. Over time, the pain intensified, being now accompanied by pleuritic chest pain and left forearm swelling, without fever. At admission, he was hemodynamically stable, exhibiting swelling and redness in the right shoulder and left forearm.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">Initial assessment revealed an ECG (figure 1) with sinus tachycardia and diffuse ST-segment elevation, increased inflammatory parameters, and a slight troponin raise. These changes prompted a Cardiology evaluation, and the echocardiogram showed a hyperechoic pericardium without effusion or wall motion abnormalities and preserved ejection fraction. Blood cultures were obtained, and ceftriaxone and clindamycin were initiated.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">After a day in the ED, his condition deteriorated, marked by high fevers, significant pulse variation, and respiratory insufficiency. A CT scan revealed abscesses in the right shoulder (figure 2), left forearm, and left iliac muscle, pleural and pericardial effusions (figure 3), leading to a new Cardiology consultation.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">The echocardiogram displayed a heterogeneous pericardial effusion (figures 4 and 5) with signs of hemodynamic compromise. Emergency pericardiocentesis drained 700 cc of purulent fluid and the patient was admitted to Intensive Care Unit. Blood cultures were positive for MSSA and flucloxacillin (12g/day) was initiated. Cardiac Surgery was consulted, and the patient was transferred for surgical assessment. A conservative approach involving alteplase administration and close monitoring ensued. Endocarditis was ruled out with a transoesophageal echocardiogram. Percutaneous drainage of remaining abscesses occurred during the hospital stay. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">After a 35-day antibiotic course, the patient was asymptomatic. At discharge, the echocardiogram revealed a hyperechoic pericardium with a minor pericardial effusion and anomalous septal movement. The patient was referred to cardiac surgery and cardiology outpatient clinics.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">In the 6 months follow-up, the patient remained symptom-free, with similar echocardiogram findings.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:12.0pt"><span style="font-family:&quot;Arial&quot;,sans-serif">Purulent pericarditis, primarily caused by <em>S. aureus</em>, can manifest suddenly with high fevers, chest pain, and tachycardia. Diagnosis is challenging, and if suspected, pericardiocentesis and empirical intravenous antibiotics should be prioritized. Aggressive treatment, including drainage, is crucial, and while surgery should be considered early, intrapericardial thrombolysis, as demonstrated with alteplase, may prevent progression to constrictive pericarditis and avoid surgery by facilitating better drainage of these typically loculated effusions.</span></span></span></span></p>