Cardiac tamponade and constrictive pericarditis due to Actinomyces meyeri bacterial pericarditis: a case report

Abstract

Background Cardiac tamponade is the most feared manifestation of purulent bacterial pericarditis (PBP), a rare form of pericarditis in immunocompetent adults. PBP remains a diagnostic challenge given its atypical associated clinical and investigative features. Consequently, PBP carries exceedingly high mortality rates due to fulminant sepsis, and morbidity including constrictive pericarditis in survivors. We present our management of a patient presenting with cardiac tamponade, who subsequently developed constrictive pericarditis due to Actinomyces meyeri PBP. Source control and symptom relief was achieved only with combined intravenous antibiotics, surgical evacuation and pericardiectomy. Case summary A 53-year-old Caucasian male presented with acute New York Heart Association Class IV symptoms, on an 8-week history of recurrent pericarditis presumed secondary to recent viral infection. Initial transthoracic echocardiography (TTE) demonstrated a large asymmetric pericardial effusion for which he underwent urgent pericardiocentesis. Unexpectedly, repeat TTE demonstrated effusion re-accumulation and effusive-constrictive pericarditis, confirmed on cardiac magnetic resonance imaging. Fluid culture was positive for Actinomyces meyeteri. He was diagnosed with primary PBP and deteriorated despite appropriate intravenous antibiotic therapy, necessitating semi-urgent surgical pericardiectomy. He recovered well and was discharged home day 10 postoperatively. Discussion Unlike uncomplicated acute viral or idiopathic pericarditis, PBP portends a very poor prognosis if unrecognised and untreated. Diagnostic challenges persist given its rarity in modern clinical practice, however PBP should be considered in cases of seemingly recurrent pericarditis. Multi-modal cardiac imaging and careful analysis of pericardial fluid including cultures and lactate dehydrogenase/serum ratios may assist in earlier recognition.