Infectious Diseases
ISSN: 2374-4235 (Print) 2374-4243 (Online) Journal homepage: http://www.tandfonline.com/loi/infd20
Myopericarditis associated with Fusobacterium nucleatum-caused liver abscess Alexis Kearney & Bettina Knoll To cite this article: Alexis Kearney & Bettina Knoll (2015) Myopericarditis associated with Fusobacterium nucleatum-caused liver abscess, Infectious Diseases, 47:3, 187-189 To link to this article: http://dx.doi.org/10.3109/00365548.2014.969306
Published online: 22 Dec 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd20 Download by: [Central Michigan University]
Date: 05 November 2015, At: 17:11
Infectious Diseases, 2015; 47: 187–189
CASE REPORT
Myopericarditis associated with Fusobacterium nucleatum-caused liver abscess
Downloaded by [Central Michigan University] at 17:11 05 November 2015
ALEXIS KEARNEY1 & BETTINA KNOLL2 From the 1Department of Emergency Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA and 2Department of Infectious Disease, Alpert Medical School of Brown University, Providence, RI, USA
Abstract A wide clinical spectrum of bacteremic disease caused by Fusobacterium has been presented in this journal. We wish to extend this spectrum by presenting a case of myopericarditis resulting from a liver abscess caused by F. nucleatum. While F. nucleatum plays an important role in periodontal disease, and has been isolated from skin ulcers, liver abscesses, urinary tract infections, and endocarditis, a single case of F. nucleatum-induced pericarditis is documented in the literature.
Keywords: Fusobacterium, abscess, myopericarditis, pyogenic liver abscess
Introduction A wide clinical spectrum of bacteremic disease caused by Fusobacterium has been presented in the Scandinavian Journal of Infectious Diseases [1]. We wish to extend this spectrum by presenting a case of myopericarditis resulting from a liver abscess caused by F. nucleatum.
Case report A 23-year-old male presented to the emergency department with chest pain. His electrocardiogram (EKG) was noted to have ST segment elevation in leads II, III, aVF, V4, V5, and V6 (Figure 1). He was brought to the Cardiac Catherization Lab, which demonstrated normal coronary arteries, but a slightly depressed ejection fraction (EF) of 45% and anteroapical hypokinesis. These findings raised concerns regarding myopericarditis. He was treated for presumed viral myopericarditis. While admitted, he experienced intermittent fevers, thought to be viral in etiology. Blood cultures were negative. His troponin peaked at 60.95. He had a leukocytosis of 19.7, with 10% bands. A subsequent echocardiogram 2 days later demonstrated a normal EF and
normal wall motion. Leukocytosis improved. He was discharged home. Nine days following hospital discharge, the patient presented with recurrent severe chest pain, radiating to the left shoulder and back, intermittent fevers, and fatigue. He was febrile to 38.7°C, and mildly tachycardic. An EKG was obtained which showed inferior Q waves and diffuse T wave inversions. Laboratory evaluation was notable for a leukocytosis of 23.1, and an INR of 1.6. His troponin and liver function tests were within normal range. On hospital day 2, he became hypotensive in the setting of fever and tachycardia. The patient was aggressively rehydrated and his blood pressure improved. Blood cultures grew F. nucleatum after 48 h of incubation. CT examination of the chest, abdomen, and pelvis with IV contrast showed two adjacent abscesses in the left hepatic lobe (Figure 2). The patient underwent evaluation for common causes of myopericarditis, including herpes simplex virus (HSV), cytomegalovirus (CMV), Epstein–Barr virus (EBV), human immunodeficiency virus (HIV), Lyme disease, and tuberculosis (TB). All were negative. A transesophageal echocardiogram was negative for endocarditis or valvular dysfunction.
Correspondence: Alexis Kearney MD MPH, 593 Eddy Street, Claverick 100, Providence, RI 02903, USA. E-mail: [email protected] (Received 2 September 2014 ; accepted 20 September 2014 ) ISSN 2374-4235 print/ISSN 2374-4243 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.969306
Downloaded by [Central Michigan University] at 17:11 05 November 2015
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A. Kearney & B. Knoll
Figure 1. EKG on initial presentation showing ST segment elevation in leads II, III, aVF, V4, V5, and V6.
The patient was diagnosed with a pyogenic liver abscess secondary to F. nucleatum, a bacterium typically found in the oropharynx and colon. The patient denied any recent dental procedures, and on examination did not have any obvious dental carries, fractured teeth or evidence of oropharyngeal infection. No colon abnormalities were found on colonoscopy.
The patient underwent percutaneous catheter drainage of the abscess. Gram stain of the drainage fluid showed gram-negative bacilli and anaerobic cultures grew F. nucleatum. The patient was started on piperacillin/tazobactam. His leukocytosis resolved. He was discharged to complete a 6 week course of ertapenem. The patient was maintained on aspirin and colchicine for myopericarditis while hospitalized.
Discussion
Figure 2. Selected image from CT of the abdomen and pelvis showing two adjacent liver abscesses located in the left hepatic lobe.
F. nucleatum is an anaerobic gram-negative rod, indigenous to the human oropharynx and colon. It is nonspore-forming and nonmotile. It plays an important role in periodontal disease. F. nucleatum has been isolated from skin ulcers, peritonsillar abscesses, septic arthritis, liver abscesses, urinary tract infections, endocarditis, and lung infections. A single case of F. nucleatum-induced pericarditis is documented in the literature [2]. In many patients, periodontal disease has been the source of infection [3]. An increased burden of F. nucleatum has also been isolated from colon cancer tissue, compared with healthy colonic tissue. Data suggest that the bacterial burden
Downloaded by [Central Michigan University] at 17:11 05 November 2015
Fusobacterium nucleatum increases with disease progression and may impact colon cancer survival [4]. F. nucleatum has been implicated in multiple cases of liver abscess and other systemic infections; however, there is only one case report of F. nucleatum resulting in pericarditis in the literature [2]. Published in 1983, this report describes a case of F. nucleatum pericarditis complicated by pericardial effusion in a 49-year-old male with a history of alcohol abuse and significant periodontal disease, who presented with a 4 day history of cough, orthopnea, diarrhea, and progressively worsening epigastric and substernal chest pain. Our patient presents a unique case of pericarditis and sepsis secondary to a liver abscess caused by F. nucleatum in an immunocompetent host. The patient’s initial presentation was concerning for viral myopericarditis; however, his work-up was negative. We hypothesize that this patient’s myopericarditis was likely a reaction to his liver abscess. Typically, viral myocarditis and pericarditis follow a benign course and resolve without overt sequelae. In this case, the patient’s symptoms did not resolve following his initial discharge from the hospital despite appropriate medical management, and actually worsened. While he did not have any abdominal tenderness and his liver function tests were normal, it
189
is not unreasonable to consider subdiaphragmatic processes in the evaluation of non-resolving or recurrent pericarditis, particularly when a viral etiology has not been identified. In this situation, a right upper quadrant ultrasound or CT of the abdomen and pelvis would be indicated to further identify potential causes of infection. Declaration of interest: Neither of the authors has any conflict of interest to disclose. No funding was received. References [1] Nohrström E, Mattila T, Pettilä V, Kuusela P, Carlson P, Kentala E, et al. Clinical spectrum of bacteraemic Fusobacterium infections: from septic shock to nosocomial bacteraemia. Scand J Infect Dis 2011;43:463–70. [2] Truant AL, Menge S, Milliorn K, Lairscey R, Kelly MT. Fusobacterium nucleatum pericarditis. J Clin Microbiol 1983; 17:349–51. [3] Bolstad AI, Jensen HB, Bakken V. Taxonomy, biology, and periodontal aspects of Fusobacterium nucleatum. Clin Microbiol Rev 1996;9:55–71. [4] Flanagan L, Schmid J, Ebert M, Soucek P, Kunicka T, Liska V, et al. Fusobacterium nucleatum associates with stages of colorectal neoplasia development, colorectal cancer and disease outcome. Eur J Clin Microbiol Infect Dis 2014; 33:1381–90.
ISSN: 2374-4235 (Print) 2374-4243 (Online) Journal homepage: http://www.tandfonline.com/loi/infd20
Myopericarditis associated with Fusobacterium nucleatum-caused liver abscess Alexis Kearney & Bettina Knoll To cite this article: Alexis Kearney & Bettina Knoll (2015) Myopericarditis associated with Fusobacterium nucleatum-caused liver abscess, Infectious Diseases, 47:3, 187-189 To link to this article: http://dx.doi.org/10.3109/00365548.2014.969306
Published online: 22 Dec 2014.
Submit your article to this journal
Article views: 50
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd20 Download by: [Central Michigan University]
Date: 05 November 2015, At: 17:11
Infectious Diseases, 2015; 47: 187–189
CASE REPORT
Myopericarditis associated with Fusobacterium nucleatum-caused liver abscess
Downloaded by [Central Michigan University] at 17:11 05 November 2015
ALEXIS KEARNEY1 & BETTINA KNOLL2 From the 1Department of Emergency Medicine, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA and 2Department of Infectious Disease, Alpert Medical School of Brown University, Providence, RI, USA
Abstract A wide clinical spectrum of bacteremic disease caused by Fusobacterium has been presented in this journal. We wish to extend this spectrum by presenting a case of myopericarditis resulting from a liver abscess caused by F. nucleatum. While F. nucleatum plays an important role in periodontal disease, and has been isolated from skin ulcers, liver abscesses, urinary tract infections, and endocarditis, a single case of F. nucleatum-induced pericarditis is documented in the literature.
Keywords: Fusobacterium, abscess, myopericarditis, pyogenic liver abscess
Introduction A wide clinical spectrum of bacteremic disease caused by Fusobacterium has been presented in the Scandinavian Journal of Infectious Diseases [1]. We wish to extend this spectrum by presenting a case of myopericarditis resulting from a liver abscess caused by F. nucleatum.
Case report A 23-year-old male presented to the emergency department with chest pain. His electrocardiogram (EKG) was noted to have ST segment elevation in leads II, III, aVF, V4, V5, and V6 (Figure 1). He was brought to the Cardiac Catherization Lab, which demonstrated normal coronary arteries, but a slightly depressed ejection fraction (EF) of 45% and anteroapical hypokinesis. These findings raised concerns regarding myopericarditis. He was treated for presumed viral myopericarditis. While admitted, he experienced intermittent fevers, thought to be viral in etiology. Blood cultures were negative. His troponin peaked at 60.95. He had a leukocytosis of 19.7, with 10% bands. A subsequent echocardiogram 2 days later demonstrated a normal EF and
normal wall motion. Leukocytosis improved. He was discharged home. Nine days following hospital discharge, the patient presented with recurrent severe chest pain, radiating to the left shoulder and back, intermittent fevers, and fatigue. He was febrile to 38.7°C, and mildly tachycardic. An EKG was obtained which showed inferior Q waves and diffuse T wave inversions. Laboratory evaluation was notable for a leukocytosis of 23.1, and an INR of 1.6. His troponin and liver function tests were within normal range. On hospital day 2, he became hypotensive in the setting of fever and tachycardia. The patient was aggressively rehydrated and his blood pressure improved. Blood cultures grew F. nucleatum after 48 h of incubation. CT examination of the chest, abdomen, and pelvis with IV contrast showed two adjacent abscesses in the left hepatic lobe (Figure 2). The patient underwent evaluation for common causes of myopericarditis, including herpes simplex virus (HSV), cytomegalovirus (CMV), Epstein–Barr virus (EBV), human immunodeficiency virus (HIV), Lyme disease, and tuberculosis (TB). All were negative. A transesophageal echocardiogram was negative for endocarditis or valvular dysfunction.
Correspondence: Alexis Kearney MD MPH, 593 Eddy Street, Claverick 100, Providence, RI 02903, USA. E-mail: [email protected] (Received 2 September 2014 ; accepted 20 September 2014 ) ISSN 2374-4235 print/ISSN 2374-4243 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.969306
Downloaded by [Central Michigan University] at 17:11 05 November 2015
188
A. Kearney & B. Knoll
Figure 1. EKG on initial presentation showing ST segment elevation in leads II, III, aVF, V4, V5, and V6.
The patient was diagnosed with a pyogenic liver abscess secondary to F. nucleatum, a bacterium typically found in the oropharynx and colon. The patient denied any recent dental procedures, and on examination did not have any obvious dental carries, fractured teeth or evidence of oropharyngeal infection. No colon abnormalities were found on colonoscopy.
The patient underwent percutaneous catheter drainage of the abscess. Gram stain of the drainage fluid showed gram-negative bacilli and anaerobic cultures grew F. nucleatum. The patient was started on piperacillin/tazobactam. His leukocytosis resolved. He was discharged to complete a 6 week course of ertapenem. The patient was maintained on aspirin and colchicine for myopericarditis while hospitalized.
Discussion
Figure 2. Selected image from CT of the abdomen and pelvis showing two adjacent liver abscesses located in the left hepatic lobe.
F. nucleatum is an anaerobic gram-negative rod, indigenous to the human oropharynx and colon. It is nonspore-forming and nonmotile. It plays an important role in periodontal disease. F. nucleatum has been isolated from skin ulcers, peritonsillar abscesses, septic arthritis, liver abscesses, urinary tract infections, endocarditis, and lung infections. A single case of F. nucleatum-induced pericarditis is documented in the literature [2]. In many patients, periodontal disease has been the source of infection [3]. An increased burden of F. nucleatum has also been isolated from colon cancer tissue, compared with healthy colonic tissue. Data suggest that the bacterial burden
Downloaded by [Central Michigan University] at 17:11 05 November 2015
Fusobacterium nucleatum increases with disease progression and may impact colon cancer survival [4]. F. nucleatum has been implicated in multiple cases of liver abscess and other systemic infections; however, there is only one case report of F. nucleatum resulting in pericarditis in the literature [2]. Published in 1983, this report describes a case of F. nucleatum pericarditis complicated by pericardial effusion in a 49-year-old male with a history of alcohol abuse and significant periodontal disease, who presented with a 4 day history of cough, orthopnea, diarrhea, and progressively worsening epigastric and substernal chest pain. Our patient presents a unique case of pericarditis and sepsis secondary to a liver abscess caused by F. nucleatum in an immunocompetent host. The patient’s initial presentation was concerning for viral myopericarditis; however, his work-up was negative. We hypothesize that this patient’s myopericarditis was likely a reaction to his liver abscess. Typically, viral myocarditis and pericarditis follow a benign course and resolve without overt sequelae. In this case, the patient’s symptoms did not resolve following his initial discharge from the hospital despite appropriate medical management, and actually worsened. While he did not have any abdominal tenderness and his liver function tests were normal, it
189
is not unreasonable to consider subdiaphragmatic processes in the evaluation of non-resolving or recurrent pericarditis, particularly when a viral etiology has not been identified. In this situation, a right upper quadrant ultrasound or CT of the abdomen and pelvis would be indicated to further identify potential causes of infection. Declaration of interest: Neither of the authors has any conflict of interest to disclose. No funding was received. References [1] Nohrström E, Mattila T, Pettilä V, Kuusela P, Carlson P, Kentala E, et al. Clinical spectrum of bacteraemic Fusobacterium infections: from septic shock to nosocomial bacteraemia. Scand J Infect Dis 2011;43:463–70. [2] Truant AL, Menge S, Milliorn K, Lairscey R, Kelly MT. Fusobacterium nucleatum pericarditis. J Clin Microbiol 1983; 17:349–51. [3] Bolstad AI, Jensen HB, Bakken V. Taxonomy, biology, and periodontal aspects of Fusobacterium nucleatum. Clin Microbiol Rev 1996;9:55–71. [4] Flanagan L, Schmid J, Ebert M, Soucek P, Kunicka T, Liska V, et al. Fusobacterium nucleatum associates with stages of colorectal neoplasia development, colorectal cancer and disease outcome. Eur J Clin Microbiol Infect Dis 2014; 33:1381–90.
