Actinomyces odontolyticus is a rare cause of pleuropericardial infection, with only 1 case identified in the literature. In that instance, the infection was believed to be secondary to gastric surgery. We present a patient with pericarditis and pericardial tamponade caused by A odontolyticus. The infection occurred after an ultrasound- guided subcarinal bronchoscopic needle biopsy performed for a suspicious mediastinal mass found on a CT scan of the chest. We describe the case presentation, the microbiology and treatment of A odontolyticus infection, and the classic features of pericarditis and cardiac tamponade.
THE CASE
A 50-year-old man with a history of Barrett esophagus presented to our emergency department (ED) with a chief concern of epigastric pain that had started at 3 AM on the day of admission. The patient described the pain as sharp and focal. It was exacerbated by inspiration and movement and was relieved by sitting forward. He also reported having a temperature of 38.8°C (102°F) for 1 week. He denied shortness of breath, nausea, vomiting, diaphoresis, and any recent history of sick contacts or travel.
Laboratory test results showed leukocytosis, with a white blood cell (WBC) count of 24.9 X 109/L (88.6% neutrophils). The patient's troponin and serum myoglobin levels were normal. A chest radiograph revealed no focal consolidation, infiltrate, or effusion and a normal cardiac silhouette. The ECG showed diffuse, concave ST-segment elevations (Figure), while the echocardiogram showed an ejection fraction of 60% (±5%) with concentric left ventricular (LV) hypertrophy, a normal LV chamber size, no evidence of systolic or diastolic dysfunction, and a small pericardial effusion.
Figure – This ECG shows diffuse, concave ST-segment elevations. These findings suggest pericarditis.
Acute pericarditis was diagnosed, and the patient was admitted for treatment and close observation. He was initially given a course of intravenous ciprofloxacin(Drug information on ciprofloxacin), 400 mg/d, and intravenous ketorolac(Drug information on ketorolac), 30 mg every 6 hours. On the morning of the second hospital day, the patient became acutely short of breath, hypotensive, and tachycardic. His heart rate rose from 114 to 120 beats per minute, and his blood pressure dropped from 108/49 to 85/50 mm Hg. His oxygen saturation remained stable at 98% on room air. An emergent echocardiogram revealed a small LV cavity, normal right atrial size with an inferior vena cava that lacked inspiratory collapse, and a moderate-sized to large circumferential pericardial effusion.
The patient was immediately taken to the cardiac catheterization laboratory for emergent pericardiocentesis; 560 mL of cloudy, yellow fluid was removed, and a pericardial drainage catheter was placed. Ciprofloxacin was discontinued, and the patient was given vancomycin(Drug information on vancomycin), 1000 mg/d, while the pericardial fluid was sent for bacterial and fungal culture, cell count, and cytology.
