Case report:
A 22-year-old immunocompetent female with a remote history of chronic right jaw osteomyelitis requiring reconstruction at age of 6 years old, and mild stable pericardial effusion first diagnosed at the age of 11, presented to our institution complaining of acute onset of fever, sharp chest pain and shortness of breath following a blunt left facial trauma four days prior.
The physical exam was remarkable for tachycardia and muffled heart tones. ECG showed diffuse concave ST-segment elevation (Figure 1 A). Complete blood count revealed leukocytosis (20.800/µl. with 86% neutrophilia). Given her otherwise stable vital signs a CT chest without contrast was performed demonstrating a large pericardial effusion in the absence of intrathoracic tumors; soon after, she became hemodynamically unstable, and a bedside transthoracic echocardiogram confirmed a large pericardial effusion with signs of cardiac tamponade (Figure 1 C-D) requiring emergency pericardiocentesis.
Using a Micropuncture technique (ref) access to the pericardial sac was obtained and a standard 8.5Fr pericardial drain was used to remove close to 900 ccs of brown thick and milky pericardial fluid (Figure 1 E). The fluid analysis demonstrated: a triglyceride level of 1298 mg/dL, cholesterol level of 103 mg/dL, cholesterol/triglyceride ratio of less than 1, absent cholesterol crystals, cytology was notable for lymphocytic predominance and negative for the presence of neoplastic cells. Microbiological analyses were significant for Streptococcus dysgalactiae subspecies equisilimis (SDSE), which is considered part of the normal oral, skin, and soft tissue flora2. In addition, the fluid analysis was negative for fungal microorganisms and acid-fast bacilli. She was treated using ceftriaxone 2g IV twice a day based on antimicrobial susceptibilities. The pericardial drain was kept for 4 days with a significant reduction in daily drainage and no accumulation of effusion on echocardiogram. However, the day after drain removal, she developed rapid re-accumulation of pericardial fluid, for this reason, a subxiphoid pericardial window was performed; severe pericardial inflammation was found, with loculated effusions that were drained. A sample of the pericardium was sent for pathology, which came back negative for malignancy.
After 10 in-hospital days, echocardiogram findings normalized, and the patient was discharged home to continue outpatient IV antibiotics for 4 weeks along with aspirin and oral colchicine therapy for 3 months. Although during the first six months of close follow-ups it seemed like the patient was directed towards a symptomatic, incessant, and chronic phase of pericarditis with thickening of the parietal pericardium by echocardiography; she responded well to a short course of oral prednisone. At the one-year follow-up, the patient remained asymptomatic with no further clinical symptoms or echocardiographic evidence of recurrent pericardial effusion.