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Chest Infections |

Coxsackie B Virus: The Enigmatic Effusion Culprit

Mark Berlacher, MD; Amber Oberle, MD; Khalil Diab, MD
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Indiana University, Indianapolis, IN


Chest. 2015;148(4_MeetingAbstracts):102A. doi:10.1378/chest.2221961
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Abstract

SESSION TITLE: Chest Infections I Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: The coxsackie family of viruses is known for its ability to manifest with a variety of clinical presentations. Specifically, Coxsackie B virus (CBV) is known for its association with myopericarditis and pleurodynia. This report describes an atypical presentation of CBV resulting in a pericardial effusion with tamponade and subsequent large volume pleural effusion.

CASE PRESENTATION: An 82 year old male presented with one month duration of progressive cough and shortness of breath. He was provided outpatient treatment with a short course of levofloxacin and prednisone after which his cough improved but dyspnea persisted. On presentation, he was normotensive with a heart rate of 105 bpm and pulsus paradoxus of 22 mm Hg. CT of the chest demonstrated a large pericardial effusion and small bilateral pleural effusions. A 2D echocardiogram confirmed the presence of a circumferential pericardial effusion measuring 2.4-2.7 cm with RV diastolic collapse. A pericardiocentesis revealed hemorrhagic fluid with negative cytology. Despite intervention, his dyspnea continued to evolve and he was found to have a large left pleural effusion necessitating drainage of nearly two liters of exudative fluid for which cytology was also negative. Suspicion for malignancy remained high however a CT chest, abdomen and pelvis, as well as a whole body PET/CT were all unrevealing. PSA, colonoscopy and EGD were also unremarkable. Upon outpatient follow up, a titer for Coxsackie B virus Type 4 was obtained and returned positive with a titer of 1:640. The patient’s dyspnea has since resolved and he has had no recurrence of his pleural or pericardial effusions.

DISCUSSION: Cases of hemorrhagic pericarditis and subsequent tamponade due to coxsackie viral infection are infrequent, with only one case reported since 2008 [1]. Even more unusual is an associated large volume pleural effusion. A high index of suspicion is required to make the diagnosis of CBV, particularly when presenting in an atypical fashion. The diagnosis can be made by viral cell culture, viral RNA PCR or retrospective serologies. Treatment of CBV infections is primarily supportive as most cases of coxsackie are self-limited [2].

CONCLUSIONS: In patients with unknown causes of pericardial and pleural effusions, the diagnosis of coxsackie viral infection should be considered.

Reference #1: Zanini, G et al. Hemorrhagic pericarditis with cardiac tamponade due to coxsackie virus infection. The Am J of Case Reports, 2009; 9: 60-63.

Reference #2: Lui, Z et al. Coxsackie-induced myocaditis: new trends in treatment. Expert Rev Anti Infect Ther. 2005 Aug;3(4):641-50.

DISCLOSURE: The following authors have nothing to disclose: Mark Berlacher, Amber Oberle, Khalil Diab

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