Case report:
A 22-year-old immunocompetent female with a remote history of chronic
right jaw osteomyelitis requiring reconstruction at age of 6 years old,
and mild stable pericardial effusion first diagnosed at the age of 11,
presented to our institution complaining of acute onset of fever, sharp
chest pain and shortness of breath following a blunt left facial trauma
four days prior.
The physical exam was remarkable for tachycardia and muffled heart
tones. ECG showed diffuse concave ST-segment elevation (Figure 1 A).
Complete blood count revealed leukocytosis (20.800/µl. with 86%
neutrophilia). Given her otherwise stable vital signs a CT chest without
contrast was performed demonstrating a large pericardial effusion in the
absence of intrathoracic tumors; soon after, she became hemodynamically
unstable, and a bedside transthoracic echocardiogram confirmed a large
pericardial effusion with signs of cardiac tamponade (Figure 1 C-D)
requiring emergency pericardiocentesis.
Using a Micropuncture technique (ref) access to the pericardial sac was
obtained and a standard 8.5Fr pericardial drain was used to remove close
to 900 ccs of brown thick and milky pericardial fluid (Figure 1 E). The
fluid analysis demonstrated: a triglyceride level of 1298 mg/dL,
cholesterol level of 103 mg/dL, cholesterol/triglyceride ratio of less
than 1, absent cholesterol crystals, cytology was notable for
lymphocytic predominance and negative for the presence of neoplastic
cells. Microbiological analyses were significant for Streptococcus
dysgalactiae subspecies equisilimis (SDSE), which is considered part of
the normal oral, skin, and soft tissue flora2. In
addition, the fluid analysis was negative for fungal microorganisms and
acid-fast bacilli. She was treated using ceftriaxone 2g IV twice a day
based on antimicrobial susceptibilities. The pericardial drain was kept
for 4 days with a significant reduction in daily drainage and no
accumulation of effusion on echocardiogram. However, the day after drain
removal, she developed rapid re-accumulation of pericardial fluid, for
this reason, a subxiphoid pericardial window was performed; severe
pericardial inflammation was found, with loculated effusions that were
drained. A sample of the pericardium was sent for pathology, which came
back negative for malignancy.
After 10 in-hospital days, echocardiogram findings normalized, and the
patient was discharged home to continue outpatient IV antibiotics for 4
weeks along with aspirin and oral colchicine therapy for 3 months.
Although during the first six months of close follow-ups it seemed like
the patient was directed towards a symptomatic, incessant, and chronic
phase of pericarditis with thickening of the parietal pericardium by
echocardiography; she responded well to a short course of oral
prednisone. At the one-year follow-up, the patient remained asymptomatic
with no further clinical symptoms or echocardiographic evidence of
recurrent pericardial effusion.