A 58-year-old man presented with weakness, vomiting, labored breathing, and severe hyperglycemia one week after a previous hospitalization for neck and chest pain. His initial work-up during the prior hospitalization included a neck CT, serial cardiac biomarkers, and telemetry monitoring, and revealed a new diagnosis of diabetes mellitus and an incidental right thyroid nodule. The pain spontaneously resolved and was diagnosed as esophageal spasm. Upon re-admission, exam revealed a toxic-appearing man with respiratory distress, slurred speech, and rapid atrial fibrillation. Labs disclosed mild leukocytosis of 12000 cells/mcL, total CK of 491 U/L with normal CK-MB fraction and troponin, and a basic metabolic panel consistent with diabetic ketoacidosis and acute kidney injury. He was treated with fluid resuscitation, insulin, and diltiazem, but rapidly decompensated, developing acute respiratory failure, renal failure, and shock. A repeat ECG revealed diffuse ST elevation, and echocardiogram showed a pericardial effusion with developing cardiac tamponade. Urgent subxiphoid pericardiostomy drained 300 mL of purulent fluid with immediate improvement in hemodynamics. Blood, sputum, and pericardial fluid cultures grew MRSA without a clear source of infection. Following a three week hospitalization involving antibiotics, insulin, mechanical ventilation, hemodynamic support, and hemodialysis, he was discharged to an LTAC, and subsequently achieved a full recovery.
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a common pathogen known to cause infections in healthy people with no risk factors. However, purulent pericarditis caused by CA-MRSA is rare, documented only in sporadic case reports. More frequently, hospital-acquired MRSA, pneumococcus, gram-negative bacilli, M. tuberculosis, and fungal organisms cause purulent pericarditis. The symptoms of CA-MRSA pericarditis are often non-specific. In this case, the patient did not have recent procedures, infections, IV drug use, or skin lesions that would indicate risk for MRSA infection. The vague presentation impeded the diagnosis until hemodynamic decompensation prompted a repeat ECG and emergent echocardiography. Empiric antibiotic therapy should begin as soon as the diagnosis is suspected or purulent material is discovered. Since early diagnosis and initiation of antibiotic therapy are essential to minimize morbidity and mortality, it is imperative that hospitalists consider CA-MRSA pericarditis as a cause of sepsis, even in patients without risk factors for CA-MRSA infection.
While CA-MRSA pericarditis is rare with few cases documented in the literature, it can cause significant mortality if untreated. Signs and symptoms may be non-specific. Diagnosis requires a high index of physician awareness for patients both with and without risk factors for MRSA.
To cite this abstract:Drake T, Goldstein D. Heart of Gold: A Case of Community-Acquired Mrsa Pericarditis with Tamponade. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 510. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/heart-of-gold-a-case-of-community-acquired-mrsa-pericarditis-with-tamponade/. Accessed April 6, 2020.