SESSION TYPE: Infectious Disease Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Acute pericarditis is the admitting diagnosis in approximately 5% of patients visiting emergency department (ED) with non-cardiac chest pain. In most patients, the cause of acute pericarditis is thought to be idiopathic. Other common causes include viral infections, renal failure, myocardial infarction (MI), malignancy, radiation, and trauma.
CASE PRESENTATION: A 34 year-old diabetic female is presents to ED with one episode of syncope. 4 weeks prior to this episode, she was treated for upper respiratory infection with cefuroxime as outpatient. Symptoms re-started 1 week back accompanied with fever, shortness of breath and some abdominal pain. CT abdomen with contrast reveals normal abdomen but 3 cm of pericardial effusion and bilateral moderate pleural effusion. She is diagnosed with viral pericarditis and discharged home on NSAIDs. At current admission, transthoracic echocardiogram reveals thickened pericardium, large pericardial effusion and early cardiac tamponade. She undergoes emergent pericardiocentesis with drainage of 800 ml amber colored fluid. It does not show any malignancy or infectious. She is discharged home. She returns to ED with left side chest pain and shortness of breath and found to have atrial flutter on Electrocardiograph. After failed medical treatment, she undergoes trans-esophageal echocardiogram and direct current-cardioversion and reverts to sinus. Chest x-ray obtained at this admission reveals multiple new bilateral pulmonary nodules, right hilar and mediastinal adenopathy, with resolved pleural and pericardial effusion. This is later confirmed with Chest CT with contrast. Oncology is consulted and she undergoes extensive blood work and imaging which turns out to be non-diagnostic. CT guided core biopsy of the right lung nodule is performed which reveals granulomatous inflammation with fungal organisms suggestive of histoplasma identified on Gomori's Methenamine Silver (GMS) stain. She is treated with itraconazole for 6 weeks with good response.
DISCUSSION: Histoplasmosis should be considered in patients with pericardial disease from endemic areas, particularly when associated with intrathoracic adenopathy unlike our case. Tissue culture is the gold standard for the definite diagnosis of the histoplasmosis but most pathologists are able to identify the budding yeasts on methenamine silver or periodic acid-Schiff staining of tissues.
CONCLUSIONS: Prompt response to anti-inflammatory medications and failure to identify H. capsulatum in the pericardial fluid or tissue support a noninfectious, inflammatory mechanism for this complication.
1) Wheat et al. Pericarditis as a manifestation of histoplasmosis during two large urban outbreaks. Medicine (Baltimore). 1983 Mar;62(2):110-9.
2) Kauffman et al. Histoplasmosis: a Clinical and Laboratory Update. CLINICAL MICROBIOLOGY REVIEWS, Jan. 2007, p. 115-132 Vol. 20, No. 10893-8512/07
3) Picardi et al. Pericarditis caused by Histoplasma capsulatum. Am. J.Cardiol. 37:82-88.
DISCLOSURE: The following authors have nothing to disclose: Puneet Agarwal, Sujay Bangarulingam
No Product/Research Disclosure InformationUniversity of Illinois, Urbana-Champaign, Urbana, IL