Emergent pericardiocentesis draining 600 mL of purulent fluid and intravenous vancomycin were used to treat isolated MRSA purulent pericarditis with cardiac tamponade in an immunocompromised man.
Case Report (n=1)
Isolated MRSA purulent pericarditis can cause cardiac tamponade in immunocompromised patients even without an identifiable primary infectious source, requiring early recognition with echocardiography and emergent pericardiocentesis.
Abstract Introduction Purulent pericarditis due to methicillin-resistant Staphylococcus aureus (MRSA) is rare in the modern antibiotic era and usually occurs in immunocompromised patients or those with risk factors such as dialysis, thoracic surgery, AIDS, or chemotherapy. Early recognition is crucial, as many cases are diagnosed only after cardiac tamponade develops or at autopsy. We present a case of isolated MRSA purulent pericarditis causing cardiac tamponade in a patient with decompensated alcoholic cirrhosis and plasma cell dyscrasia without an identifiable infectious source. Case Presentation A 70-year-old man with decompensated alcoholic cirrhosis presented with fever, weakness, and altered mental status. Laboratory evaluation revealed leukopenia, thrombocytopenia, and mild transaminitis. CT imaging showed cirrhosis with splenomegaly and multiple lytic lesions of both femoral diaphysis. Serum free kappa light chains were markedly elevated (17,643 mg/L) with a small monoclonal spike, raising concern for plasma cell dyscrasia. During hospitalization, the patient developed hypoxic respiratory failure and new atrial fibrillation along with hemodynamic compromise. Repeat chest CT revealed a large pericardial effusion with early tamponade (Figure 1). Echocardiography confirmed significant pericardial effusion with tamponade physiology. Emergent pericardiocentesis drained 600 mL of purulent fluid. Pericardial cultures grew MRSA, while blood and respiratory cultures remained negative. Brain MRI ruled out septic emboli. The patient remained on intravenous vancomycin, and the pericardial drain continued to yield serosanguinous fluid. No primary infectious focus was identified. In this immunocompromised host with cirrhosis and evolving plasma cell dyscrasia, transient or occult bacteremia was suspected to have seeded the pericardium, resulting in isolated MRSA purulent pericarditis. Discussion MRSA purulent pericarditis is exceptionally rare, with only a few cases reported in the literature. Immunosuppression remains one of the most common predisposing factors. Most patients have a preceding infection such as pneumonia, osteomyelitis, bacteremia, or endocarditis, but none were present in our patient. This case highlights the diagnostic challenge of purulent pericarditis, where symptoms are often nonspecific and many cases are diagnosed only after the development of cardiac tamponade or at autopsy. The reported incidence of tamponade in purulent pericarditis ranges from 42-77%. Early use of point-of-care ultrasound (POCUS) or echocardiography is crucial in any hemodynamically unstable patient with risk factors for MRSA infection. Clinicians should consider this diagnosis in immunocompromised patients presenting with sepsis or shock, even without an obvious source of infection. This abstract is funded by: None
Vankina et al. (Fri,) conducted a case report in Isolated MRSA purulent pericarditis causing cardiac tamponade (n=1). Emergent pericardiocentesis and intravenous vancomycin was evaluated. Emergent pericardiocentesis draining 600 mL of purulent fluid and intravenous vancomycin were used to treat isolated MRSA purulent pericarditis with cardiac tamponade in an immunocompromised man.