First case of invasive meningococcal disease‐induced myopericarditis in a patient with human immunodeficiency virus infection

Abstract

A 47-year-old man presented to our intensive care unit in May 2018 with a 2-day history of abdominal pain, fever, vomiting and diarrhoea. The patient has been known to be human immunodeficiency virus (HIV)positive since 1998 and reported his risk for HIV as men having sex with men (MSM). At admission, we noted: blood pressure 83/66 mmHg, heart rate 119 b.p.m., oxygen saturation 96% on room air and temperature 36.9 C. Laboratory analysis showed elevated C-reactive protein (335 mg/L), leukocytosis (41 × 10 white blood cells/L, of which 95.7% were neutrophils) and troponin Ic level of 207 pg/mL (normal <14 pg/mL). An electrocardiogram (ECG) revealed ST elevation in inferior leads coupled with diffuse repolarisation abnormalities. After 2 days of hospitalisation, mixed cardiogenic and septic shock appeared. Procalcitonin and troponin Ic levels were elevated respectively to 58 μg/L and 466 pg/mL. Life support with veno-arterial extracorporeal membrane oxygenation was established. A transthoracic echocardiogram (TTE) showed reduced left ventricular systolic function (LVSF) of less than 10% associated with a large pericardial effusion and right ventricular diastolic collapse consistent with cardiac tamponade (Fig. 1). Emergency surgical pericardial drainage was performed and yielded purulent fluid with the presence of Gram-negative diplococci on Gram stain. Antibiotic therapy with cefotaxime-clindamycin plus amikacin was commenced. By Day 5 an aerobic blood culture came back positive for Neisseria meningitidis. The strain belonged to serogroup C, sequence type 11. The antibiotic treatment was switched to cefotaxime-rifampicin for 8 days. No other microorganism was isolated from blood cultures or pericardial fluid. The patient had never been vaccinated against meningococcus and his CD4 cell count was 189 cells/mm. By Day 27 post-admission, cardiac function had recovered by repeated TTE and blood cultures were negative. Invasive meningococcal disease (IMD) is a serious bacterial infection caused by the Gram-negative diplococcus, N. meningitidis. HIV infected patients have an elevated risk for IMD compared with the general adult population, particularly immunocompromised men with a CD4 cell count less than 200/μL. Among HIV-positive patients, IMD usually presents as bacteraemia and/or meningitis, but other clinical forms have also been described such as invasive pneumonia and septic arthritis. Here we have reported the first case of IMD-induced myopericarditis in a HIV-infected patient. Among patients suffering from IMD without HIV infection, previous cases of meningococcal myocarditis and pericarditis were diagnosed through a combination of positive blood cultures for N. meningitidis, clinical presentation, myocardial cytolysis, newly ECG changes and impaired LVSF on TTE. In the present case, the diagnosis was made based on positive blood cultures and pericardial fluid, markedly elevated troponin, newly ECG abnormalities and major impaired LVSF with tamponade. However, the clinical presentation was unusual. Notably, IMD presenting with abdominal features has been increasingly described in recent years, especially with hyperinvasive isolates of meningococci, including serogroup C ST11 as reported here. HIV-positive MSM subjects are peculiarly susceptible to these isolates, as shown by the outbreak of IMD started in France in the Paris region in June 2013. Vaccination against serogroup C meningococci is currently recommended in France at the age of 12 months, with a catch-up in children and young adults (13 months to 24 years). Following the outbreak of IMD among MSM, the French Council of Public Health issued a recommendation to target all MSM aged 25 years and older