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Cardiac Tamponade and Fatal Arrhythmia Caused by Cardiac Actinomycosis Attributable to Actinomyces meyeri FREE TO VIEW

Yoshikazu Yamaji, MD; Kazunori Tobino, MD; Mina Asaji, MD; Keisuke Anan, MD; Yuichiro Yasuda, MD; Kosuke Tsuruno, MD; Noriyuki Ebi, MD
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Chest. 2013;144(4_MeetingAbstracts):208A. doi:10.1378/chest.1704194
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SESSION TITLE: Infectious Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Actinomycosis is most commonly caused by Actinomyces israelii (A. israelii), and A. meyeri is rarely isolated in patients with this illness. A. meyeri appears to have the greatest capability of causing disseminated actinomycosis (defined as the involvement of two distant organs) [1]. However, there was no report about cardiac actinomycosis due to this pathogen, to our knowledge. We report the first case of cardiac tamponade and fatal arrhythmia due to cardiac actinomycosis attributable to A. meyeri, in which the patient survived through medical management.

CASE PRESENTATION: A 56-year-old Japanese man referred to our hospital with dyspnea, orthopnea and hypotension. He had a history of Parkinson’s disease with psychosis. He reported having left-sided chest pain and productive cough of two months’ duration. Examination of the oral cavity revealed poor dentition and inadequate hygiene. Jugular venous pressure was elevated to the angle of the jaw at 45°. Laboratory test values were as follows: white blood cells, 29,950/mm3 with a left shift; serum C-reactive protein (CRP), 17.25 mg/dl (normal, < 0.2 mg/dl). The chest CT scan showed a wedge-shaped and pleural-based mass in the left upper lobe (LUL), thick-walled cavitary lesion containing water density in the left lower lobe (LLL), bilateral pleural effusions and pericardial effusion. The patient underwent emergent pericardiocentesis and placement of pericardial drainage tube, which yielded approximately 800 ml of purulent fluid and restored blood pressure. Thoracentesis was also performed on both sides and revealed slightly yellow and hazy pleural fluid. Gram stain and cytologic examination of the pericardial and pleural fluid did not show any organisms and also malignant cells. Examination of sputum showed no predominant pathogen. Two sets of blood culture specimens did not yielded any organisms. The patient was initially diagnosed as a bacterial pericarditis and lung abscess in the LLL, and empiric antimicrobial therapy with intravenous ceftriaxone was started. On the sixth day of admission, the pericardial tube drainage was minimal and the drainage tube was removed. At the morning of the ninth day, a fever of 39.0 degrees Celcius developed, and sinus tachycardia (150/minute) suddenly occurred. After the tachycardia which continued for four hours, the patient became atrial fibrillation and became cardiac arrest with asystole. Immediate cardiopulmonary resuscitation was performed. On the same day, ultrasound-guided pneumocentesis of the cavitary lesion in the LLL was performed and 35 ml of purulent fluid was obtained. Gram stain of the fluid showed Gram-positive filamentous rods, and cultures from the fluid grew Actinomyces species. The fluid was also analyzed using a method for clone library sequencing of the 16S ribosomal DNA (rDNA) gene and revealed A. meyeri along with other anaerobes (Fusobacterium species). Antibiotics were changed to intravenous penicillin on the 11th day, and the treatment was continued for four weeks. The patient’s condition continued to be stable, and he was discharged on oral therapy with doxycycline after a five-week hospitalization.

DISCUSSION: Actinomyces species are normal inhabitants of man's oral cavity, and poor dental hygiene, aspiration and trauma are predisposing factors for initial infection [3]. Our patient was 56-year-old male and had risk factors including poor dental hygiene and mental disorders. Cardiac involvement usually results from the direct extension of thoracic disease [4]. Our patient had concomitant pulmonary involvements as a probable primary site of infection, therefore, it was thought that the pericardial involvement was caused by contiguous spread from the adjacent thoracic disease.

CONCLUSIONS: This is the first case who survived cardiac tamponade and fatal arrhythmia caused by cardiac actinomycosis attributable to A. meyeri, which was initially difficult to diagnose.

Reference #1: Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: case report and review. Clin Infect Dis. 1996;22:621-5.

Reference #2: Burden P. Actinomycosis. J Infect 1989;19:95-9.

Reference #3: Datta JS, Raff MJ. Actinomycotic pleuropericarditis. Am Rev Respir Dis. 1974;110:338-41.

DISCLOSURE: The following authors have nothing to disclose: Yoshikazu Yamaji, Kazunori Tobino, Mina Asaji, Keisuke Anan, Yuichiro Yasuda, Kosuke Tsuruno, Noriyuki Ebi

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