5 ps: opossum bite causing purulent pericarditis leading to pericardial tamponade secondary to pasteurella multocida

SESSION TITLE: Images in Chest Medicine SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Purulent pericarditis with pericardial tamponade is a rare, life-threatening disease with high mortality. We report the first case of purulent pericarditis with pericardial tamponade in a 77 year old lady secondary to Pasteurella multocida due to an opossum bite. CASE PRESENTATION: A 77-year-old female with a history of breast cancer in remission presented with dyspnea, chest pressure, and fatigue for one week. On initial exam, she was tachycardiac, tachypneic, and hypotensive with elevated jugular venous pressure, positive Kussmaul's sign, muffled heart sounds with cold extremities, and delayed capillary refill. Initial pertinent data showed leukocytosis (white blood cell 29.51 K/uL), brain natriuretic peptide (BNP 300 pg/ml), elevated inflammatory markers, EKG with diffuse ST segment elevations and PR segment depression. A computed tomography (CT) chest showed a large pericardial effusion with reflux of contrast into the inferior vena cava and hepatic veins, diffuse thickening, and enhancement of the pericardium. A cardiac point of care ultrasound (POCUS) showed a large circumferential pericardial effusion with compression of the right atrium early in diastole and dilation of the inferior vena cava, an inspiratory increase of tricuspid flow velocities and the expiratory increase of mitral flow velocities. She underwent urgent pericardiocentesis which yielded 350 cc of thick, salmon-colored fluid with a total nucleated count of 613,3000/MCL, predominantly 53% neutrophils and 47% monocytes. Blood cultures and pericardial fluid cultures grew Pasteurella multocida, fluid cytology was negative for malignant cells, and histopathology showed acute fibrinous pericarditis. On further history, she recalled an opossum bite to her finger a few months before admission requiring partial left fourth-digit amputation, and endorsed intermittent exposure to opossums in her garden. She underwent pericardial window and washout, discharged home on IV ampicillin-sulbactam for six weeks with no recurrence of disease on follow-up. DISCUSSION: Purulent pericarditis is a rare condition seen in immunosuppressed patients with a neutrophil predominant infection characterized by gross or microscopic purulence in the pericardium. Pasteurella multocida is a gram-negative coccobacillus, usually associated with dog or cat bites and cat scratches, rare from bites or exposure to non-feline or canine animals. Opossums are commonly found in North America, with rare instances of human bites causing diseases like leptospirosis, tuberculosis, tularemia, toxoplasmosis, coccidiosis, trichomoniasis, and Chagas disease. In our case, the patient underwent a fourth-digit amputation secondary to an opossum bite during gardening six months before her presentation with no further complications or symptoms. Due to her immunosuppression, she was at a higher risk of developing infections; however, it is unclear how she developed a delayed presentation of acute pericarditis leading to pericardial tamponade. CONCLUSIONS: We report the first case of purulent pericarditis with pericardial tamponade as a late complication of an opossum bite six months before her presentation. It carries a high mortality rate, especially in immunocompromised individuals. In some cases, pericardial tamponade is the initial presenting symptom as a delayed presentation of acute pericarditis. Timely identification of acute symptoms with urgent pericardiocentesis and early initiation of antibiotics identifying the underlying etiology plays a crucial role in mortality prevention. REFERENCE #1: Farhat-Sabet A, Hull R, Thomas D. Cardiac Tamponade from Purulent Pericarditis due to Cutibacterium acnes. Case Reports in Cardiology. 2018;2018:4739830. doi: 10.1155/2018/4739830. REFERENCE #2: Barlam TF, Kasper DL. Infections Due to the HACEK Group and Miscellaneous Gram-Negative Bacteria. Harrison's Principles of Internal Medicine, 20e. New York, NY: McGraw-Hill Education; 2018. REFERENCE #3: Vesza Z, Boattini M, Pinto M. Pasteurella infections in a tertiary centre - from cellulitis to multiple-organ failure: Retrospective case series. SAGE Open Med Case Rep. 2017;5:2050313x17748286. Epub 2018/01/11. doi: 10.1177/2050313x17748286. PubMed PMID: 29318015; PubMed Central PMCID: PMCPMC5753917 DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer ingelheim Please note: present Added 04/13/2023 by Allen Anderson, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with Merck Please note: current Added 04/13/2023 by Allen Anderson, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with pfizer Please note: present Added 04/13/2023 by Allen Anderson, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Edwards Life Sciences Please note: present Added 04/13/2023 by Allen Anderson, source=Web Response, value=no financial support No relevant relationships by Stephanie Ibrahim No relevant relationships by Mir Mahnoor No disclosure on file for Abhishek Pandya No disclosure on file for Omar Sheikh