university of ottawa heart institute -...
TRANSCRIPT
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