Purulent pericarditis with Salmonella enteritidis in a patient with CD4/CD8 depression

More than 200 serovars of salmonella are pathogenic in humans. Salmonella enteritidis is the most common pathogen after Salmonella typhi, and usually causes gastroenteritis. Up to 5% of patients have demonstrated the pathogen in their blood. Five to 10% of people carrying these bacteria have been associated with cardiovascular complications, including endocarditis or bacterial aortic aneurysm, etc. []. We report here a case of effusive-constrictive pericarditis (ECP) following purulent pericarditis caused by S. enteritidis, which has rarely been reported. ECP is an uncommon pericardial syndrome characterized by intense pericardial effusion, concomitant tamponade, and constriction caused by the visceral pericardium [].

A 65-year-old male with stable angina pectoris was admitted to our hospital complaining of high-grade fever with a shaking chill and general fatigue. Stable angina pectoris had been treated with aspirin, diltiazem and nitroglycerin for 5 years. His body temperature was 39.0 °C and his blood pressure was 164/84 mmHg. Heart rate was 98/min and regular, and paradoxical pulse was not apparent. His heart sound showed neither murmur nor pericardial friction rub. No peripheral edema and hepatomegaly were observed. In laboratory examinations, the white blood cell count was 11800/mm³ with 85% neutrophils, and C-reactive protein was 35.8 mg/dl. Chest X-ray revealed cardiomegaly (CTR 62%) and bilateral pleural effusions. Electrocardiogram (ECG) showed concave upward ST-segment elevation in I, II, III and aVF. Twenty-four days later, ECG demonstrated negative T wave in I, II, III, aVF, aVL and V2-6. A two-dimensional view of the echocardiogram revealed a large amount of pericardial effusion around the heart, and neither right atrium nor ventricular apparently collapsed. Emergency pericardiocentesis was performed, and 630 ml of fluid was drained. Pericardial effusion contained high white cell counts and the total protein value was 5.7 g/dl. S. enteritidis was detected by a culture study of the fluids. No malignant cells were detected. The pleural effusion also showed the same exudative pattern, but S. enteritidis was not seen. The results of the concomitant blood and stool cultures were negative for Salmonella. No primary source of salmonella could be confirmed. While, he was diagnosed as CD4/CD8 depression (0.81 < 1.0) which suggested immunodeficiency, but he did not have a malignant disease, HIV infection or blood disease.

The clinical course of the patient is shown in Fig. 1. He was treated with cefotiam and fosfomycin for 10 days, ampicillin and isepacin for 4 weeks, and oral antibiotics were administered for the next several months. A cardiac catheterization was performed 50 days after admission. Coronary angiography showed severe stenosis in proximal site of right coronary artery. Right atrium and ventricular pressure were shown by fluid filled record. Right atrium average pressure and right ventricular systolic pressure demonstrated elevated level (17 mmHg and 38 mmHg, respectively). Right ventricular pressure in diastole showed a dip and plateau (Fig. 2). This paper was recorded by 50 mm per 1 s. These were associated with constrictive pericarditis and a pericardial effusion of mild size remained on the echocardiography. As stated above, we diagnosed subacute ECP. C-reactive protein returned to within normal limits, and the pericardial effusion disappeared after 2 months. He did not develop recurrent pericarditis or right heart failure. On cardiac catheterization after one year, right ventricular pressure did not show a dip and plateau.

Purulent pericarditis represents about 1% of acute pericarditis. It may be more acute, and is often associated with high fever, shaking chill and sepsis. It usually occurs with Streptococcus pneumoniae, Hemolytic streptococcus, Staphylococcus aureus, Nesseria and Legionella []. There are few case reports of pericarditis with non-typhoidal salmonella. There have been less than 30 case reports; S. typhimurium was the most frequently isolated, and represents about 50% of reported cases []. Purulent pericarditis with S. enteritidis has rarely been reported. Non-typhoidal salmonella may spread from gastrointestinal tract or abscess to the pericardium through blood. Although a stool culture sample did not show bacteria S. enteritidis, there is a possibility to be infected from a carrier of the bacteria because he had a habitual enema using coffee.

Important predisposing factors for the development of pericarditis include immunosuppresion with underlying disease or immunotherapy, and pre-existing pericardial effusion with uremia or thoracic surgery []. We thought that the present patient might be an immunocompromised host based on CD4/CD8 depression, but he did not have any underlying diseases (e.g. malignant disease, HIV infection, absess or blood disease) and had not been treated with a steroid or immunosuppressive agent. The measurement of CD4/CD8 was required when pulurent pericarditis was improved. CD4/CD8 depression might transiently be admitted. Hancock [] first reported ECP including diagnosis and hemodynamic feature. Due to combined clinical course, cardiac catheterization and echocardiography, we diagnosed subacute ECP. Further evaluation of right atrium pressure waveform (type W) and manometer sticking on the catheter tip was required for the presize diagnosis of ECP.

Purulent pericarditis sometimes presents serious clinical course to cardiac tamponade or cardiac death, and diagnostic aspiration, pericardiocentesis [] and long-term antibiotic therapy are required. Dolin et al. [] reported the only previous case in 1991, and the present case might be the second case. Due to the long-term use of antibiotics without an operative procedure, his hemodynamic state improved. He did not develop recurrent pericarditis or right heart failure due to constrictive pericarditis.