Rapidly progressing purulent pericarditis caused by Neisseria meningitides infection

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INTRODUCTION: Purulent pericarditis is an uncommon clinical manifestation of infection due to Neisseria meningitides [1]. Early differentiation of purulent pericarditis from viral pericarditis is critical due to life-threatening complications such as cardiac tamponade. We present a case of a patient with rapidly progressing purulent pericarditis associated with meningococcal bacteremia. CASE PRESENTATION: A 56-year-old male with a history of HIV on HAART (CD4 count of 952 cells/mL) presented to the emergency department with pleuritic chest pain and low-grade fevers. He denied headache, neck stiffness, or sick contacts. He was tachycardic, afebrile, and normotensive upon arrival. On cardiac auscultation heart sounds were normal with no audible murmur or pericardial rub and jugular veins were not distended. Initial lab workup was significant for a white blood cell count of 20.8 bil/L and lactic acid of 2.3 mmol/L. Electrocardiogram revealed diffuse ST elevations and transthoracic echocardiogram demonstrated a small pericardial effusion. A presumptive diagnosis of acute viral pericarditis was made and the patient was started on colchicine. Quickly, within 12 hours, he developed worsening chest pain, tachycardia, and hypotension. CT of the chest with contrast was negative for pulmonary embolism but revealed a large circumferential pericardial effusion confirmed by echocardiography, which also showed evidence of early tamponade physiology. The patient was taken for an emergent pericardiocentesis with drainage of 370 cc of purulent fluid, which was negative by culture, with rapid improvement of hemodynamics. Blood cultures obtained on admission grew beta lactamase negative Neisseria meningitides group C. He was discharged home in stable condition with a twoweek course of IV ceftriaxone and a three-month course of colchicine. Follow-up echocardiogram six weeks after discharge demonstrated near resolution of the pericardial effusion with no evidence of constriction. DISCUSSION: Since the introduction of antibiotics, purulent bacterial pericarditis accounts for less than one percent of cases of pericarditis in developed countries [2]. While Neisseria meningitides classically manifests as meningitis and bacteremia, it is important to be aware of this potential complication [1]. Prognosis depends on prompt detection, antibiotic initiation, and drainage due to complications such as life-threatening cardiac tamponade or constrictive pericarditis [3]. This is clearly demonstrated by the rapidly enlarging pericardial effusion with development of tamponade physiology in our patient. CONCLUSIONS: This case underscores the importance of recognizing a rare presentation of meningococcal infection as purulent pericarditis and the need for early treatment due to its rapid progression.




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