Polymicrobial Purulent Pericarditis Probably caused by a Broncho-Lymph Node-Pericardial Fistula in a Patient with Tuberculous Lymphadenitis

Abstract

Purulent pericarditis is a rare condition with a high mortality rate. We report a case of purulent pericarditis subsequently caused by Candida parapsilosis, Peptostreptococcus asaccharolyticus, Streptococcus anginosus, Staphylococcus aureus, Prevotella oralis, and Mycobacterium tuberculosis in a previously healthy 17-year-old boy with mediastinal tuberculous lymphadenitis. The probable route of infection was a bronchomediastinal lymph node-pericardial fistula. The patient improved with antibiotic, antifungal, and antituberculous medication in addition to pericardiectomy.

Keywords: Bronchial fistula; Pericarditis; Polymicrobial infection; Tuberculous lymphadenitis; Tuberculous pericarditis.

Figure 1. Anteroposterior chest radiograph; the cardiac silhouette is globularly enlarged and looks like a "water bottle".

Figure 2. Chest computed tomography. Transverse section image shows a large amount of pericardial effusion with pericardial enhancement (panel A). Multiple necrotic lymph nodes containing air density are observed in the pretracheal (panel B, arrow) and subcarinal areas (panel C, arrow). Coronal section image shows subcarinal lymph node with air density in contact with the parietal pericardium (panel D, arrow).

Figure 3. Hospital course of the patient and identified pathogens from pericardial fluid cultures. Hospital day 2: The TB PCR text was positive for the initial pericardial fluid and also positive for those samples obtained at day 4 and 10. Hospital day 2 to 4: Serial AFB stains of sputum and pericardial fluid were all negative. Hospital day 3: The initial pericardial fluid culture yielded yeast growth. Hospital day 4: Candida parapsilosis was identified from the pericardial fluid and gram-positive cocci was observed in the pericardial fluid culture. Hospital day 7: AFB stain of pericardial fluid was positive. Hospital day 9: Polymicrobial pathogens were identified subsequently from the initial pericardial fluid culture. Hospital day 10: AFB stain of the pericardial fluid from the operation field was positive. TB cultures of pericardial fluid performed five times were all negative.

AFB, acid fast staining; TB PCR, tuberculosis polymerase chain reaction; INH, isoniazid; RFP, rifampin; EMB, ethambutol; PZA, pyrazinamide; HD, hospital day; MSSA, methicillin susceptible Staphylococcus aureus. ^aHD#1 - Culture was requested on hospital day 1. ^bPericardial fluid culture requested at hospital day 1 was reported at hospital day 4.

Figure 4. Anteroposterior chest radiograph obtained on day 7 of hospitalization; the cardiac silhouette decreased in size but a newly developed radiolucent lesion around the heart with left costophrenic angle blunting can be seen (arrows).

Figure 5. Chest computed tomography on day 7 of hospitalization: A transverse section image shows pericardial effusion was slightly decreased but multifocal air density and septations in pericardial space (panel A, arrow) were observed. In the coronal section image, subcarinal lymph node within air density (panel B, arrow) appears unchanged, and percutaneous pericardial drainage tube in pericardial space (panel B, arrowhead) is observed.