candIda alblcans PunJlent Pericarditis "n'eated Successfully without Surgical Drainage· RkhtJrrl Karp, M.D.;t Raymond Meldahl, M.D.;* and Robert McCabe, M.D., EC.C.P.t Cures or Candida pericarditis reported in the literature uniformly involved surgical drainage of the pericardiaI space, We report a patient with purulent pericarditis caused by CmttIidtJ olbicmu who was treated suceessfuDy with antifungal chemotherapy combined with a single pericardiocentesis that did DOt completely evacuate the pericardial space. This case indicates that thoracotomy with s~ drainage or the pericardium is DOt mandatory for suceessful therapy of Candida pericarditis. (Clam 1992; 102:953-54)
P reported
urulent pericarditis caused by Candida species is rarely in the literature and is usually lethal. Surgical drainage and pericardiectomy combined with antifungal chemotherapy were used when therapy was successful. 1-3 ~ report a case of Candida pericarditis in an immunocompetent patient who was treated successfully with amphotericin B and 8ucytosine without surgical drainage or pericardiectomy. CASE REPORT
A 62-year-old man with a history of angina choked on a piece of meat, foUowed by strenuous vomiting and then dyspnea. while on a fishing trip in Alaska. Surgery demonstrated a 1.5-cm tear in the esophagus, perforation of the left mediastinal pleura, and undigested food in the mediastinum. The perforations were repaired, pleural chest tubes were placed, and broad-spectrum antibiotics were administered. He was discharged 26 days after hospital admission and he returned to California. Two weeks later, he developed dyspnea and inspiratory incisional ·From the Medical Service, Martinez VA Medical Center, Martinez, Calif, and the Department of Medicine, University of California Medical School, Davis. tFellow, Infectious Diseases. tAssistant Clinical Professor of Medicine. tAssociate Professor of Medicine. &print reqtIUts: Dr. McCabe, Meclkal Service (1llF). Martinez VA Medical Center; Martinez, CA 94553
chest pain. The following day he was mildly dyspneic, temperature was 38.9"C, blood pressure was 13M30 mm Hg without paradox, and pulse was 120 beats/min. His neck had no jugular vein distention, and a systolic ejection murmur and diastolic friction rub ~ heard, Chest roentgenogram showed cardiomegaly and displacement of the epicardial fat line, and electrocardiogram was without ST segment and T-wave abnormalities and not changed significantly from four years previous. White blood cell count was 14,()()(Vcu mm and arterial blood Po. was 66 mm Hg while breathing room air. Oxygen and ceftizoxime were given, ventilation-perfusion lung scan did not indicate pulmonary embolism, but echocardiogram showed a moderate pericardial effusion (Fig lA). On hospital day 2, pericardiocentesis yielded 140 ml of purulent material resulting in decreased size of the etrusion by echocardiogram. A drain could not be placed for technical reasons. Gram stain of the aspirate showed debris, white blood cells, a few Gram-positive cocci in chains, and abundant budding yeast (Fig IB). Aerobic and anaerobic cultures grew only Candido allncans. Vancomycin, amphotericin B, and 8ucytosine were administered in addition to oeftizoxime immediately after the pericardiocentesis. Subsequently, penicillin was substituted for vancomycin and ceftizoxime. Susceptibility testing of the C allnca,., isolate by a macrodiIution broth technique (done by David Stevens, M.D., Institute for Medical Research, San Jose, Calif) indicated susceptibility to amphotericin B (MIC
P reported
urulent pericarditis caused by Candida species is rarely in the literature and is usually lethal. Surgical drainage and pericardiectomy combined with antifungal chemotherapy were used when therapy was successful. 1-3 ~ report a case of Candida pericarditis in an immunocompetent patient who was treated successfully with amphotericin B and 8ucytosine without surgical drainage or pericardiectomy. CASE REPORT
A 62-year-old man with a history of angina choked on a piece of meat, foUowed by strenuous vomiting and then dyspnea. while on a fishing trip in Alaska. Surgery demonstrated a 1.5-cm tear in the esophagus, perforation of the left mediastinal pleura, and undigested food in the mediastinum. The perforations were repaired, pleural chest tubes were placed, and broad-spectrum antibiotics were administered. He was discharged 26 days after hospital admission and he returned to California. Two weeks later, he developed dyspnea and inspiratory incisional ·From the Medical Service, Martinez VA Medical Center, Martinez, Calif, and the Department of Medicine, University of California Medical School, Davis. tFellow, Infectious Diseases. tAssistant Clinical Professor of Medicine. tAssociate Professor of Medicine. &print reqtIUts: Dr. McCabe, Meclkal Service (1llF). Martinez VA Medical Center; Martinez, CA 94553
chest pain. The following day he was mildly dyspneic, temperature was 38.9"C, blood pressure was 13M30 mm Hg without paradox, and pulse was 120 beats/min. His neck had no jugular vein distention, and a systolic ejection murmur and diastolic friction rub ~ heard, Chest roentgenogram showed cardiomegaly and displacement of the epicardial fat line, and electrocardiogram was without ST segment and T-wave abnormalities and not changed significantly from four years previous. White blood cell count was 14,()()(Vcu mm and arterial blood Po. was 66 mm Hg while breathing room air. Oxygen and ceftizoxime were given, ventilation-perfusion lung scan did not indicate pulmonary embolism, but echocardiogram showed a moderate pericardial effusion (Fig lA). On hospital day 2, pericardiocentesis yielded 140 ml of purulent material resulting in decreased size of the etrusion by echocardiogram. A drain could not be placed for technical reasons. Gram stain of the aspirate showed debris, white blood cells, a few Gram-positive cocci in chains, and abundant budding yeast (Fig IB). Aerobic and anaerobic cultures grew only Candido allncans. Vancomycin, amphotericin B, and 8ucytosine were administered in addition to oeftizoxime immediately after the pericardiocentesis. Subsequently, penicillin was substituted for vancomycin and ceftizoxime. Susceptibility testing of the C allnca,., isolate by a macrodiIution broth technique (done by David Stevens, M.D., Institute for Medical Research, San Jose, Calif) indicated susceptibility to amphotericin B (MIC
