Case 3 presentation

John P. Veinot MD, FRCPC

Professor of Pathology & Cardiology

University of Ottawa

Ottawa Hospital, Ottawa Heart Institute

UNIVERSITY OF OTTAWA HEART INSTITUTEUNIVERSITY OF OTTAWA HEART INSTITUTEUNIVERSITY OF OTTAWA HEART INSTITUTEUNIVERSITY OF OTTAWA HEART INSTITUTE

Clinical

• 51 year old married male

• 2 pack/ day smoker

• recent diagnosis of hypertension

• flu like illness - fever, pleuriticchest pain

Clinical

• admitted to peripheral hospital,

treated for pericarditis with NSAID

• presented to ER with chest pain ,

dyspnea, fever and elevated JVP

• query tamponade, and transferred to Heart Institute

Clinical

• Physical exam: HR 120, BP 120/60 with pulsus paradoxicus,

• JVP elevated with Kussmauls sign, • basal crackles; no friction rub

• Lab: WBC 16, Hb 103, ALP 226, CK 31

• ECG: diffuse T wave abnormalities with mild depression of the PR segment

• ECHO

Clinical

• Echo

significant pericardial effusion and impending tamponade

• Provisional diagnosis: viralpericarditis with tamponade

Clinical

• Pericardiocentesis: 620 ml serosanguinousfluid, culture and cytology negative, started on Entrophen 650 mg bid

• CT chest: multiple small nodules possiblymetastatic disease

• Respirology consult: recommended R/O TB

• prednisone 40 mg daily for 10 days

• left thoracentesis 630 ml turbid yellow fluid, culture and cytology specimen clotted so not sent, pleural biopsy reactivemesothelial cells

Case History continued

• repeat ECHO

extrinsic mass from pericardial space

through epicardium to endocardium

into RV cavity

• CT chest

Homogeneous RV apical mass, multiple pulmonary nodules

Clinical history

• ? TB

• ? Malignancy

• ? Primary ? angiosarcoma

• ? Malignancy ? metastatic

Clinical

• Chemotherapy planned

• Oncologist wanted tissue biopsy to

plan chemo type

• Right ventricle endomyocardial

biopsy was planned

Clinical

• RV endomyocardial biopsies

• sent for pathology and culture

• verbal pathology report –

abscess

Case History continued

• RV biopsy pathology reviewed: Actinomycosis

• Culture - gram positive bacilli later

detected by broth culture, but did not grow on agar

• ID - penicillin 3 million units IV q4h

• Dental consult recommended

Clinical history

• Penicillin treatment

• Recurrent dyspnea, JVP distended to

angle of jaw sitting, 20-30 mm Hg

pulsus paradoxicus

• repeat echo - effusive constrictive organizing pericarditis - no tamponade

• fluid overload from sodium in penicillin

aggravating constrictive physiology, treated with IV furosemide

Follow up

• Mass decreased in size

• PICC line – penicillin for months

• 22 teeth extracted, gingivoplasty

• Developed a pericardial friction rub as fluid disappeared

• ? developing constriction – eventual

pericardiectomy probably required

Actinomycosis• 5 species including Actinomyces

israeli, otherwise calledPropionibacterium propionicus

• Gram positive anaerobic bacillus, non-acid fast, branched filaments,

• sulfur granules - Actinomycoticgranules - organized aggregates of filaments encapsulated by granulation tissue

• Often found around teeth and tonsils

Actinomycosisclassification

• Cervicofacial: most common, frequently after dental extraction, may develop abscesses and draining sinuses

• Thoracic: may develop from aspiration or from extension of cervicofacialinfection, may spread to pericardium

• Abdominal: may spread from thorax or through the wall of the stomach or intestines

Pericardial Actinomycosis• Most originate from a thoracopulmonary

site

• followed by direct spread to the

pericardium

• Treatment - high dose prolonged antibiotics

• 9 of 11 survivors or 82% - drainage of

the pericardial space

• 5 underwent pericardiectomy• Fife TD, Finegold SM. Reviews of Infectious Disease 1991; 13: 120-126

Pericardial Actinomycosis: Case Report and Review 18 cases in

literature

• Risk factors: aspiration pneumonia, alcohol abuse, periodontal disease

• Cultures are often negative and

histology is often necessary

• Mean time from onset of symptoms to diagnosis 25 weeks

• Fife TD, Finegold SM. Reviews of Infectious Disease 1991; 13:

120-126

An Uncommon Cause of

Pericardial ActinomycosisEspositi D et al. Ital Heart J 2000; 1: 632-35

• Pericardial actinomycosis arising from a draining fistula from the liver,

• prior jejunostomy for pancreatitis 2 years before

• died despite pericardiocentesis followed by laparotomy

• Echo - reflective masses within pericardial space attributed to aggregates of sulfur granules

Actinomyces odontolyticus thoracopulmonary infections.

Two cases in Lung and Heart-Lung Transplant Recipients and a Review of the Literature

Bassari AC et al. Chest 1996; 109: 1109-1111

• First case: 10 months following single lung transplant, subacute apical infiltrate in native lung responded to oral penicillin

• Second case: pyogenic mediastinitis 25 days after heart-lung transplant requiringsternal debridement and penicillin

Follow up

• Mass gone

• Lung nodules gone

• Stopped drinking

• Back to work