A fatal Candida albicans pericarditis presenting with cardiac tamponade after COVID-19 infection and cardiothoracic surgery

BACKGROUND

Candida pericardial infection is a rare clinical entity usually related to recent cardiothoracic surgery and chronic debilitating conditions. During the COVID-19 pandemic, invasive fungal infections have been on the rise, likely due to a combination of factors such as immunosuppression, underlying conditions like diabetes, and surgical procedures.

CASE PRESENTATION

Herein, we report a 67-year-old diabetic woman with a history of COVID-19 infection who received a high dose of corticosteroids a few months before admission, and previous myocardial infarction for more than 12 years. The patient had a positive cardiac tamponade with signs of dyspnea, chest pain, and low blood pressure. Echocardiographic data were more in favor of constrictive pericarditis. The patient underwent urgent echocardiography-guided pericardiocentesis and then broad-spectrum antibiotic treatment was prescribed. Repeated echocardiography implied a persistent pericardial effusion 10 days later. Subxiphoid aspirates and biopsied tissues showed budding yeast cells and yeast colonies grew on culture media identified as Candida albicans.

CONCLUSION

This report should bring to the attention of physicians toward the possibility of Candida pericardial infection presenting with cardiac tamponade after COVID-19 infection and cardiothoracic surgery. Echocardiographic assessment, prompt pericardiotomy, molecular-based identification of causative agent, and early administration of appropriate antifungal treatment should improve the patient's survival.

Commensal and multidrug-resistant Neisseria spp. sepsis in feline

INTRODUCTION

Sepsis is a serious problem in felines with a mortality rate ranging from 29-79%. Neisseria spp. is considered a commensal microorganism of the oral cavity of dogs and cats and is usually isolated from human wounds resulting from bites of these animals.

CASE REPORT

The present report describes clinical, imaging and laboratory findings of a feline with sepsis wherein commensal and multidrug-resistant (MDR) Neisseria spp. was isolated. The feline presented a history of four days of anorexia, dyspnea, prostration, and, pericardial, pleural and abdominal effusions. Pericardiocentesis was performed and hemorrhagic exudate was observed. The animal died after 11 days of treatment with gentamicin and amoxicillin combined with clavulanic acid. During necropsy, the abdominal cavity was found to be filled with greenish-yellow content and the pericardial sac was thickened with a large amount of purulent secretion. Histopathology revealed sepsis with necrotizing suppurative pericarditis, diffuse mononuclear pneumonia and necrotic pleuritis, leading to secondary bacterial infection.

CONCLUSIONS

Commensal Neisseria spp. are important zoonotic bacteria, which trigger a serious disease in felines. However, it has not been reported to cause sepsis with pneumonia, suppurative necrotizing pericarditis and pericardial effusion.

Myocarditis and Pericarditis following COVID-19 mRNA Vaccination: Practical Considerations for Care Providers

The mRNA vaccines against COVID-19 infection have been effective in reducing the number of symptomatic cases worldwide. With widespread uptake, case series of vaccine-related myocarditis/pericarditis have been reported, particularly in adolescents and young adults. Men tend to be affected with greater frequency, and symptom onset is usually within 1 week after vaccination. Clinical course appears to be mild in most cases. On the basis of the available evidence, we highlight a clinical framework to guide providers on how to assess, investigate, diagnose, and report suspected and confirmed cases. In any patient with highly suggestive symptoms temporally related to COVID-19 mRNA vaccination, standardized workup includes serum troponin measurement and polymerase chain reaction testing for COVID-19 infection, routine additional lab work, and a 12-lead electrocardiogram. Echocardiography is recommended as the imaging modality of choice for patients with unexplained troponin elevation and/or pathologic electrocardiogram changes. Cardiovascular specialist consultation and hospitalization should be considered on the basis of the results of standard investigations. Treatment is largely supportive, and myocarditis/pericarditis that is diagnosed according to defined clinical criteria should be reported to public health authorities in every jurisdiction. Finally, we recommend COVID-19 vaccination in all individuals in accordance with the Health Canada and National Advisory Committee on Immunization guidelines. In patients with suspected myocarditis/pericarditis after the first dose of an mRNA vaccine, deferral of a second dose is recommended until additional reports become available.

A Rare Case of Pyopericardium After Blunt Thoracic Trauma

The bacterial purulent pericarditis is rapidly progressive and represents a highly fatal infection, with mortality rates reaching up to 100% if untreated. Approximately 40% to 50% of all cases are caused by Gram-positive bacteria, especially Streptococcus pneumoniae. We describe an extremely rare case of S. pneumoniae purulent pericarditis as a delayed complication of a blunt thoracic trauma. The patient was successfully treated with urgent pericardiocentesis, thoracoscopic pericardial fenestration, and broad-spectrum antibiotics. Owing to the high mortality rate of a purulent pericarditis, a high index of suspicion is needed in order to instaurate an appropriate therapy with drainage and antibiotics.

Cryptococcal pericarditis in a heart transplant recipient

We present a case of Cryptococcus neoformans pericarditis in a cardiac transplant recipient. This article reviews the diagnosis, treatment, and complications of cryptococcosis specifically in transplant patients. While pericarditis is a rare manifestation of Cryptococcus infection, this case highlights that cryptococcosis should be considered in the differential diagnosis for solid organ transplant and immunocompromised patients presenting with pericardial effusions.

The First Report of Purulent Pericarditis Associated with Aortic Stent-graft Infection Caused by Methicillin-susceptible Staphylococcus aureus

We herein report the first case of purulent pericarditis associated with aortic stent-graft infection in an 80-year-old Japanese man that was caused by methicillin-susceptible Staphylococcus aureus, which appropriate antibiotics failed to treat. The detailed clinical course and autopsy images revealed that purulent pericarditis associated with aortic stent-graft infection caused cardiac tamponade and eventually led to mortality. We therefore suggest that surgical procedures, including drainage, should be introduced for such cases.

[Infected Thoracic Aortic Aneurysm Secondary to the Purulent Pericarditis;Report of a Case]

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/µl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography( CT). As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair (TEVAR). The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.

A case report of purulent pericarditis caused by Candida albicans: Delayed complication forty-years after esophageal surgery

RATIONALE

Candida pericarditis is a rare condition with high mortality. Risk factors include thoracic surgery and immunosuppression. We report a case of candida pericarditis which developed forty-years after esophageal reconstruction surgery.

PATIENT CONCERNS

A 42-year-old female presented with nausea, abdominal discomfort, and chest pain, and was found to have a cardiac tamponade secondary to candida pericarditis. Her notable risk factor was colonic interposition done during her infancy for esophageal atresia.

DIAGNOSES

The patient underwent emergent pericardial window where 500cc of purulent fluid was drained. The pericardial fluid culture grew Candida albicans.

INTERVENTIONS

Esophagram did not show any visible leak and the patient improved with surgical drainage and antifungal treatment with Caspofungin. Caspofungin was continued intravenously for a total of four weeks and was switched to fluconazole.

OUTCOMES

An Echocardiogram performed one month after pericardial window revealed trivial pericardial effusion. Serum beta-D-glucan at the time was negative.

LESSONS

This report highlights that candida pericarditis infection could occur as a late complication of colonic interposition. We also demonstrate the utility of using an echinocandin in treating this entity.

Acute Myopericarditis Associated with Tickborne Rickettsia sibirica mongolitimonae

We report an unusual case of myopericarditis caused by Rickettsia sibirica mongolitimonae. Because of increasing reports of Rickettsia spp. as etiologic agents of acute myopericarditis and the ease and success with which it was treated in the patient reported here, rickettsial infection should be included in the differential diagnosis for myopericarditis.

Pericardial Window for Methicillin-Resistant Staphylococcus aureus Pericarditis

A 58-year-old man presented with tamponade and underwent an emergency pericardiocentesis. We made the diagnosis of methicillin-resistant Staphylococcus aureus pericarditis based on culture results and treated the patient with pericardial drainage and antibiotics as the first-line therapy. After temporary relief, reaccumulation of effusion developed. We successfully created a pericardial window using thoracotomy, and the patient's postoperative course was uneventful. Methicillin-resistant Staphylococcus aureus pericarditis is an extremely rare and life-threatening illness. No consensus exists concerning the ideal surgical intervention. Creating a pericardial window using thoracotomy can be an effective definitive therapy for methicillin-resistant Staphylococcus aureus pericarditis, especially for patients with significant pericardial adhesions.

Successful treatment of community-acquired methicillin-resistant Staphylococcus aureus purulent myopericarditis

A previously healthy 48-year-old active duty man, who had been treated for an elbow abscess 3 weeks earlier, presented to an emergency department in Bahrain with tachycardia, pericardial friction rub and jugular venous distention. Cardiac tamponade was confirmed on transthoracic echocardiogram and he was taken for emergent pericardiocentesis. Pericardial fluid cultures grew community-acquired methicillin-resistant Staphylococcus aureus Despite ongoing treatment with intravenous vancomycin, he developed a recurrent fibrinous pericardial effusion and constrictive pericarditis requiring pericardiectomy. Though he initially did well postoperatively, he developed drug reaction with eosinophilia and systemic symptoms syndrome in response to vancomycin. He was transitioned to ceftaroline and started on high-dose steroids. He recovered during a week-long admission and was discharged home. Several weeks later at follow-up he was doing well and had resumed moderate intensity exercise.

Purulent Pericarditis with Salmonella enterica Subspecies arizona in a Patient with Type 2 Diabetes Mellitus

Purulent pericarditis is a life-threatening disorder, even in the modern antibiotic era. Although diabetes mellitus is known to be associated with an increased risk of multiple types of infections, purulent pericarditis is extremely rare. We herein report an unusual case of pericarditis caused by Salmonella enterica subspecies arizona that was not associated with any evident underlying immunosuppressive disorder apart from uncontrolled type 2 diabetes mellitus. Because a pet snake was suspected as being the source of infection in the present case, patient education and a detailed review of exposure history could play an important role in treating patients with diabetes mellitus.

Disseminated MRSA infection with purulent pericarditis

The risk of developing pericarditis secondary to Methicillin-Resistant Staphylococcus aureus (MRSA) infection in the absence of preceding surgical procedure is extremely low. We present a case report of a 36-year-old woman who developed disseminated MRSA infection leading to purulent pericarditis.

Fulminant Pneumococcal Pericarditis in a Previously Healthy Patient

Purulent pericarditis is a rare acutely life-threatening condition. Initial symptoms, signs, and investigations can be nonspecific. Echocardiography is invaluable for establishing the diagnosis and initial management. We present a case of a previously healthy patient with purulent pericarditis caused by Streptococcus pneumoniae in the absence of a primary focus of infection. The patient deteriorated rapidly with cardiac tamponade and septic shock and was managed successfully by a combined medical and surgical approach.

Pericardial Infusion of Tissue Plasminogen Activator in Fibropurulent Pericarditis

A 61-year-old man developed a loculated fibropurulent pericarditis, a rare complication of bacteremia. This occurred as a complication of a Staphylococcal aureus bacteremia from a head and neck abscess following self-extraction of a tooth. Despite surgical intervention and placement of 2 pericardial drains, a refractory, inadequately drained infected pericardial effusion persisted. Although there is limited experience with thrombolytic therapy to dissolve a fibrin clot in the pericardium, break down loculated adhesions, and facilitate free drainage of infected material, lysis is well described in the management of exudative pleural effusions. After infusion of 30 mg of tissue plasminogen activator in 100 cc normal saline through the pericardial drain of the patient, a large amount of infected serosanginous material subsequently drained during the next 2 days. The patient became afebrile and culture negative, remained hemodynamically stable, and had resolution of his pericarditis and pericardial effusion on electrocardiogram and echocardiogram, respectively.

Microbiologic and Pathologic Findings in an Epidemic of Equine Pericarditis

During the spring and summer of 2001 and in association with the mare reproductive loss syndrome, 22 terminal and 12 clinical cases of equine pericarditis were diagnosed in central Kentucky. Actinobacillus species were the principal isolates from 8 of 10 nontreated, terminally affected and 3 of 10 clinically affected horses. Enterococcus faecalis and Streptococcus zooepidemicus were cultured from the remaining 2 nontreated terminal cases. No viruses were isolated in tissue culture. Nucleic acid of equine herpesvirus-2 was detected in pericardial and tracheal wash fluids of 3 and 1 individuals, respectively. Microscopic alterations in sections of heart and parietal pericardium were consistent with chronic fibrinous bacterial pericarditis. This report confirms a significant role of Actinobacillus species in equine pericarditis and describes an epidemic of this infrequently observed syndrome in the horse.

Choice of drainage procedure in paediatric pyopericardium: a 30-year experience

Although there is general agreement on the necessity of draining pyopericardium, debate continues as to the safe and effective method of drainage. Studies describing head-to-head comparison of various drainage procedures are very few and are disadvantaged by small numbers of cases. In this observational study, we review our 30-years experience with different techniques of pericardial drainage. Between 1972 and 2003, the authors have personally treated 39 children who suffered from pyopericardium. Among the 22 children who underwent early partial pericardiectomy, 20 were alive. In contrast to this,12 out of 15 children treated with repeated pericardiocentesis or sub-xiphoid tube drainage were dead. The median hospital stay for pericardiectomy group was 18 days (range 11-32) and that for the non-thoracotomy group was 34 days (range 18-55 days).

With regard to immediate survival and early convalescence in the pyopericardium, partial pericardiectomy is superior to pericardiocentesis and sub-xiphoid tube drainage. Pericardiocentesis can be used for diagnostic or temporizing purposes, but not as the definitive drainage procedure. Partial pericardiectomy can be done even in small hospitals where heart-lung machines are not available.

Cardiac Tamponade Due to Actinomyces odontolyticus Originating From a Dentigerous Cyst

This report describes a rare case of pericardial effusion owing to Actinomyces odontolyticus in a 52-year-old woman that originated from a dentigerous cyst, which developed on the distal aspect of a lower left third molar. The cyst had remained asymptomatic for a long period, with no specific functional complications. This is the first case report of a patient with acute pericarditis in which the same strain of A odontolyticus was detected in an asymptomatic dentigerous cyst and in the pericardial fluid.

Genetic characteristics of Streptococcus dysgalactiae isolated from cage cultured cobia, Rachycentron canadum (L.)

Disease outbreaks occurred during 2007-2013 in Taiwan with 2.5-10% mortality among the cage cultured cobia, Rachycentron canadum (L.), characterized by the presence of polyserositis, pericarditis and peritonitis. The micro-organisms isolated from internal organs were Gram-positive cocci. The isolates were confirmed as Streptococcus dysgalactiae by a polymerase chain reaction assay that yielded the expected specific 259 bp amplicon. Additionally, partial sequence of the 16S-23S rDNA intergenic spacer region of the GCS strain isolates from fish was also compared and produced 100% sequence identity with S. dysgalactiae (GenBank accession number AB252398). The genetic characterization was then determined by pulsed-field gel electrophoresis (PFGE) analysis. Based on PFGE, the Apa I or Sma I digestion patterns of chromosomal DNA of these isolates were grouped into three main clusters. Taiwanese strains were divided into two clusters, and the tet(M) gene was detected in cluster 1 (pulsotypes: A1-A2 and S1-S3), but not in cluster 2 strains (pulsotypes: A3-A4 and S4-S5). Three Japanese strains from amberjack, Seriola dumerili (Risso), were grouped into cluster 3 (pulsotypes: A5-A7 and S6-S8) and displayed no mortality to cobia in the challenge experiment. Conversely, Taiwanese strains from cobia and snubnose pompano, Trachinotus blochii (L.), displayed a mortality rate of 50-87.5% in cobia.

[Acute pericarditis and tamponade: An unusual revelation of a visceral tuberculosis]

Tuberculosis is a common pulmonary disease, which is still endemic in disadvantaged communities. Pericarditis is a rare but very lethal visceral localization. The authors report the case of a 58-year-old man, without neither medical history nor social risk, who presented a cardiac tamponade as the first and atypic manifestation of a visceral tuberculosis.

Acute Primary Pneumococcal Purulent Pericarditis With Cardiac Tamponade: A Case Report and Literature Review

Bacterial pericarditis is a rapidly progressive and highly fatal infection, and is often diagnosed postmortem in half of the cases. Even with drainage and antibiotics, the mortality rate is high. Gram-positive cocci, specifically Streptococcus penumoniae, have been the most common cause of bacterial pericarditis with a preceding primary site of infection. Following the introduction of antibiotics in the 1940s and more recently the pneumococcal conjugate vaccine, the incidence has drastically decreased.We describe an extremely rare case of primary streptococcus pneumoniae purulent pericarditis that presented with cardiac tamponade. The patient was successfully treated with broad-spectrum antibiotics and urgent pericardiocentesis.Due to the high mortality rate with purulent pericarditis, a high index of suspicion is needed when acute pericarditis is suspected for early diagnosis to instate appropriate therapy with antibiotics and drainage.

Bacterial pancarditis with myocardial abscess: successful surgical intervention in a 14-month-old boy

A 14-month-old boy with a structurally normal heart presented with signs of cardiac tamponade caused by purulent pericarditis. During his hospital stay, mitral and tricuspid valve endocarditis developed, and a ventricular septal abscess expanded despite appropriate, prolonged antibiotic therapy for methicillin-resistant Staphylococcus aureus. The day before scheduled surgical correction, the abscess ruptured, creating a septal aneurysm. Surgical intervention resulted in an excellent outcome. Throughout the patient's 67-day hospitalization, the use of echocardiography was crucial in monitoring and diagnosis. In addition to reporting this case, we discuss our diagnostic and treatment considerations. To our knowledge, this is only the 4th report of S. aureus bacterial pancarditis with myocardial abscess.

Anicteric leptospirosis with pneumonitis, pericarditis and acalculous cholecystitis

We report the case of a 19-year-old male patient admitted to hospital with fever, asthenia, vomiting, abdominal and chest pains, cough with yellowish sputum, and hypotension. Laboratory tests showed leukocytosis and high creatine phosphokinase levels, without hyperbilirubinaemia or renal failure. The tomographic images of the chest and abdomen showed a right basal pneumonia and acalculous cholecystitis. The electrocardiograms revealed significant characteristics of acute pericarditis. Specific serology for leptospirosis done in the second and third weeks of disease showed positive results. The use of ceftriaxone 1g intravenously, twice a day for 7 days, resulted in an overall clinic improvement. The role of the suspicion index for diagnosis of leptospirosis is emphasized in anicteric patients, as well as the unsuspected possibility of pulmonary, pericardial and gallbladder involvement.

Management of persistent purulent pericarditis using streptokinase for intrapericardial fibrinolysis

Purulent pericarditis (PP) is a very serious condition with almost 100% mortality if untreated. Intrapericardial fibrinolysis is a preferred alternative to pericardectomy in the treatment of persistent PP, but there are no consensus guidelines on the standard protocol for this procedure in children. A 9-year-old boy was referred to the Medical Research Council Unit in The Gambia (MRC). He had been unwell for 18 days with a high continuous fever, cough, fast breathing, and dyspnoea on exertion. Prior to referral he had been treated for malaria and pneumonia with no improvement. At the MRC, he was diagnosed with purulent pericarditis caused by Staphylococcus aureus and after admission he was managed for 4 weeks with intravenous antibiotics, pericardial aspirations followed by saline lavage of the pericardium and intrapericardial antibiotic instillation. Despite these measures, massive re-accumulation of the purulent pericardial effusion continued. Once daily intrapericardial instillation of streptokinase at a dose of 18,000 i.u/kg diluted in 50 ml of normal saline, and saline washout of the pericardium after 2 hours was commenced on the 29th day of admission, in addition to the antibiotics. This technique of fibrinolysis employed for 2 days was effective in managing the persistent purulent pericarditis when pericardial aspiration and intravenous and intrapericardial antibiotics failed.

Cardiac tamponade complicating purulent pericarditis due to community acquired methicilin resistant Staphylococcus aureus (CA-MRSA)

Community acquired methicillin resistant Staphylococcus aureus(CA-MRSA) is a global pathogen capable of causing life-threatening infections with increasing prevalence since the 1990s. Purulentpericarditis, characterized by accumulation of purulent fluid in the pericardial space was historically a disease of the pediatric and early adult population, but through the years the median age of diagnosis has increased from 21 to 49. Mortality rates are as high as 40% even in the treated population. We report a case of purulent pericarditis due to CA-MRSA that was complicated by cardiac tamponade. Early diagnosis and intervention proved to be life-saving. A brief review of the literature and current management options are discussed.

Beware the normal angiogram

Purulent pericarditis is now rare due to the widespread use of antibiotics. However, it is associated with significant morbidity and mortality, and non-specific symptoms and signs can make diagnosis difficult. We report a patient who presented with left-sided chest pain, mild fever and ST segment elevation on electrocardiography, who required prolonged organ support in the intensive care unit. This lesson highlights the diagnostic difficulties and management challenges that this condition can present.

[Pericarditis as initial presentation of disseminated meningococcal disease]

Pericarditis is a well-recognized but uncommon complication of meningococcal infection. The incidence of pericarditis complicating meningococcal disease in all age groups is reported to be 3-19%. There are few cases reported in the paediatric age group. Disseminated meningococcal disease with pericarditis, defined as purulent pericarditis with clinical evidence of disseminated meningococcemia and meningitis. We report the case of a 4-month-old male infant who presented disseminated meningococcal disease with pericarditis caused by Neisseria meningitidis serogroup B. The patient was treated with antibiotic with excellent response. It is important to point out that meningococcal disease may present in unusual forms which may lead to diagnostic and therapeutic difficulties.

Five children with purulent pericarditis and review of the literature

Purulent pericarditis in children is a life-threatening disease that requires early diagnosis and immediate intervention. This cardiac emergency is rarely seen in the western world. However, cases of purulent pericarditis are still being reported in developing countries. We describe our experience with five cases of purulent pericarditis in children seen between 1998 and 2002. Haemophilus influenzae bacteria were isolated in all except one case. With active management, all five children survived.

[Immune-mediated pericarditis in a patient with meningococcal meningitis]

Extrameningial manifestations in patients with meningococcal meningitis are rare. One of these manifestations is immune-mediated or purulent pericarditis. We present a case where a patient with meningococcal meningitis developed pericarditis on the 11th day after admission. A pericardial puncture was performed but the pericardial fluid regenerated after two days despite antibiotic treatment. The pericardial fluid showed no bacterial growth and PCR for bacterial DNA was negative. Subsequent steroid treatment proved to be effective, indicating a case of immune-mediated pericarditis.

Cardiac tamponade likely due to candida infection, in an immunocompetent patient

Candida pericarditis is a rare disease described mainly in immunodepressed patients. Here we report the case of a 76-year-old immunocompetent woman who developed a purulent pericarditis 48 hours after pericardiocentesis. Usual etiologies such as cancer or pericardo-oesophageal fistula, were ruled out. Physical examination revealed a sub-mammary mycosis, which could have led to the infection. The early diagnosis and treatment with a combined medical and surgical approach succeeded in a favorable evolution of this case.

Purulent pericarditis caused by Haemophilus parainfluenzae

Bacterial pericarditis is a rare disease in the era of antibiotics. Purulent pericarditis is most often caused by Staphylococcus aureus, Streptococcus pneumoniae, or Haemophilus influenzae. The number of H. parainfluenzae infections has been increasing; in rare cases, it has caused endocarditis. We report a case of purulent pericarditis caused by H. parainfluenzae in a 62-year-old woman who reported a recent upper respiratory tract infection. The patient presented with signs and symptoms of pericardial tamponade. Urgent pericardiocentesis restored her hemodynamic stability. However, within 24 hours, fluid reaccumulation led to recurrent pericardial tamponade and necessitated the creation of a pericardial window. Cultures of the first pericardial fluid grew H. parainfluenzae. Levofloxacin therapy was started, and the patient recovered. Haemophilus parainfluenzae should be considered in a patient who has signs and symptoms of purulent pericarditis. Prompt diagnosis, treatment, and antibiotic therapy are necessary for the patient's survival. To our knowledge, this is the first report of purulent pericarditis caused by H. parainfluenzae.

Purulent pericarditis and cardiac tamponade caused by Nocardia farcinica in a nephrotic syndrome patient

Nocardiosis is an uncommon infection that occurs primarily in immunocompromised patients. We herein report an extremely rare case of Nocardia farcinica (N. farcinica) pericarditis. A 53-year-old man with nephrotic syndrome that required chronic corticosteroid therapy presented with pleuritic chest pain and cardiac tamponade. Pericardiocentesis revealed purulent pericardial effusion and a bacteriological examination showed the characteristic branching filamentous bacteria identified as N. farcinica. Aggressive surgical drainage and a trimethoprim-sulfamethoxazole based regimen resulted in clinical improvement. To the best of our knowledge, this is the first reported case of N. farcinica pericarditis in Thailand.

An unusual case of fatal pericarditis due to Listeria monocytogenes

Pericarditis due to Listeria monocytogenes is a very uncommon and serious disease. We describe a case of fatal subacute pericarditis that was caused by L. monocytogenes in a 61-year-old woman with Hodgkin's disease who was diagnosed in 1975 and considered cured. In addition, we review the literature on this condition.

Complication of etanercept treatment for rheumatoid arthritis--purulent pericarditis caused by a commensal organism

The patient presented with increasing fatigue and dyspnoea. The patient had medical history of rheumatoid arthritis for which she had been taking methotrexate for the past 15 years and etanercept for the past 6 years. Initial diagnosis was cardiac failure but further investigation by echocardiogram revealed a large pericardial effusion. Empirical piperacillin-tazobactam was started due to moderately raised inflammatory markers. Four hundred millilitre of frank pus was aspirated from the pericardial sac and antimicrobial treatment was changed to meropenem. Gram positive cocci were seen in the initial Gram stain, but conventional cultures remained negative. However, 16S ribosomal RNA gene sequencing of the pus sample detected the presence of Parvimonas micra genome. Reaccumulation of the effusion required further drainage where again P micra was detected by 16S ribosomal RNA gene sequencing. Two weeks of meropenem was completed followed by treatment with benzylpenicillin and metronidazole.