549: BROKEN DOORWAY OF THE HEART! A RARE CASE OF DOUBLE-VALVE GEMELLA ENDOCARDITIS WITHOUT BACTEREMIA

Abstract

Learning Objectives: Cardiac tamponade is a life threatening condition requiring immediate intervention. Methods: An 18-year old previously healthy female recently treated for costochondritis presented with dyspnea, intermittent fever/ chills, and acute worsening chest pain. ECG and CXR were negative. Labs were significant for CRP 16mg/dL, ESR 49mg/dL, and WBC 11,500mm3. TTE showed left atrial compression with possible extracardiac mass. CT chest imaging revealed a 6x5cm subcarinal mass with compression of the left atrium and pulmonary vein as well as calcified mediastinal lymph nodes. Routine cultures, fungal, and TB studies were sent. She developed increased tachypnea and tachycardia along with worsening labs (e.g., CRP/ ESR; WBC 27,300mm3; LDH 220U/L). Rapid strep throat test was negative and urinalysis was unremarkable. Progressive tachycardia and tachypnea prompted a bedside TTE, revealing a large pericardial effusion with fibrinous exudate. Cardiac tamponade was demonstrated with significant compression of both the right atrium and ventricle in the setting of her worsening clinical status. An emergent bedside pericardiocentesis was performed with frank exudate and a pericardial window was placed. Empiric antibiotics were initiated. Repeat imaging demonstrated mediastinitis and a left-sided loculated effusion requiring a chest tube. Respiratory status continued to worsen requiring intubation. A right-sided thoracotomy was done for abscess drainage and lymph node sampling. Extubation was attempted after the procedure, but failed. Antibiotics were narrowed to ampicillin after cultures grew Microaerophilic, Eikenella, and Haemophilus. Tissue and lymph node biopsies revealed reactive lymphoid tissue without malignancy or granulomas. Histoplasma yeast antibodies with complement fixation were positive (titer 1:128 [>1:32 indicate strong evidence of histoplasmosis]). Work-up was negative for histoplasmosis urinary antigen, tuberculosis, sarcoidosis, HIV, AFP, and HCG. Antimicrobials were broadened to ampicillinsulbactam and voriconazole secondary to suspicion for granulomatous mediastinitis due to histoplasmosis with 6 and 12 weeks of treatment, respectively. While ventilator parameters improved, she was unable to be weaned for extubation due to deconditioning and required a tracheostomy. Results: Purulent pericarditis and resultant tamponade were believed to be a result of a microscopic esophageal tear likely secondary to the original subcarinal mass compressing the esophagus.