From Skin Infection to Pericardiectomy: A Cautionary Tale of Undertreated Methicillin-Resistant Staphylococcus aureus

Abstract

Background. Perimyocarditis is an inflammation of the pericardium and myocardium. Infrequently, perimyocarditis can be associated with bacterial infections. Few cases have been documented of purulent perimyocarditis secondary to community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). This is a case presentation on perimyocarditis due to CA-MRSA. Case Presentation. A 48-year-old male Naval officer with no significant prior medical history was deployed in Bahrain and presented with malaise and fevers. On exam, he was found to have a right elbow abscess with surrounding cellulitis. The abscess was incised and drained. Cultures of abscess fluid identified MRSA. Linezolid was prescribed but stopped one day later after a presumed drug rash developed. Desloratadine and prednisolone were administered and the rash resolved. No antibiotics were restarted. Nineteen days later, patient re-presented with shortness of breath, chest pain, persistent fevers, and syncope. A transthoracic echocardiogram revealed a large pericardial effusion with tamponade physiology and a reduced left ventricular ejection fraction (25%). On admission, laboratory tests were notable for leukocytosis with left shift, troponin I 3.26 ng/dL, and blood cultures growing MRSA. Emergent pericardiocentesis was performed and 750cc of sanguinous fluid was aspirated with cultures isolating MRSA. Intravenous vancomycin was started. Patient was transferred to a U.S. facility once hemodynamically stable. A repeat echocardiogram indicated a smaller but loculated effusion with heavy fibrinous content and constrictive physiology not amenable to repeat pericardiocentesis. Surgical complete pericardectomy was performed. Post-operative echocardiogram showed an improved ejection fraction (40-45%). At discharge, he was hemodynamically stable. Two months later, he re-presented with congestive heart failure and persistent myocarditis evident on cardiac MRI. He was medically managed and discharged home. Results. This case illustrates catastrophic consequences of CA-MRSA perimyocarditis. Conclusion. This patient likely developed purulent perimyocarditis due to an inadequately treated soft tissue infection and brief immunosuppression for a presumed drug reaction. Increasing awareness of CA-MRSA perimyocarditis will allow for early diagnosis and decreased mortality.