Download Bacterial infections of the myocardium and pericardium.

Prof. Petar M. Seferović, MD, PhD, FESC, FESC
Bacterial infections of the
myocardium and pericardium
Department of Cardiology of
the University Medical Center Belgrade, Serbia
Bacterial infections of
myocardium and pericardium
PURULENT
MYOCARDITIS
BACTERIAL
INFECTION
MYOCARDIUM
LYME BORELIOSIS
MYOCARDITIS
PURULENT
PERICARDITIS
PERICARDIUM
TUBERCULOUS
PERICARDITIS
BACTERIAL
PERICARITIS
IN AIDS
Maisch B, Seferović PM et al. Eur Heart J 2004;25(7):587-610
Bacterial (purulent) myocarditis
Pathophysiological and clinical hints
 Rare disease, but with high mortality
 Can be caused by virtually any
bacterial agent (Clostridium sp.,
C.diphteriae, Streptococcus,
M.tuberculosis)
 Myocardial manifestations can be
masked by general infection, often
clinically unrecognized
 Acute and fulminant forms frequent
 Mostly in imunocompromized
patient and children
Lyme myocarditis
Lyme disease transmission – Two year cycle
Lyme disease
Clinical stages
Stage I
 “Flu like” symptoms, 25% have “bull’s eye” rash
(antibiotics effective at this stage)
Stage II
 Muscle aches, fatigue, joint pain, “migratory
arthritis”, meningitis
Stage III
 Severe chronic neurological symptoms, syncopy,
chest pain, psychosis, fatigue (neuroboreliosis
and cardioboreliosis)
Infectious Pericarditis
Lyme myocarditis
Borrelia burgdorferi
cardiac envolvement:
 Myopericarditis
 Conduction
abnormalities
 Acute pericarditis/
pericardial effusion
Lyme myocarditis
Clinical presentation
Transient myocardial inflammation (10% of patients)
• Prevalence: Unknown, but probably increasing
Variable degrees of atrio-ventricular block
Syncope
Diffuse ST segment and T waves abnormalities
Fever, chills, myalgias
Fatigue
Dyspnea at exertion
Arrhythmias (supraventricular and ventricular)
Asymptomatic
Heart failure
Schultheiss HP. Dtsch Med Wochenschr. 2008 Dec;133 Suppl 8:S290-4
Kühl U. Drugs. 2009;69(10):1287-302
Lyme pericarditis
Diagnostic and therapeutic approach
 Gallium scan may be useful
 Biopsy is rarely needed
 Treating early manifestation
can prevent development of
late complications
 Acutely, temporary
transvenous pacing may be
required for a week
 Routine use of intravenous
antibiotics is suggested
CLINICAL VALUE FOR THE PRACTICING CARDIOLOGIST
Oriented on the practical dilemmas of the routine cardiology
Recommendations for simple and straightforward procedures
Controversies and non-resolved issues highlighted
Infectious pericarditis
Etiology
 Viral infection (Coxsackie, echovirus, influenza, adenovirus, HIV,
Parvo B19)
Bacterial infection (Staphylococcus, Streptococcus, gramnegative bacilli, Meningococcus, Pneumococcus, Salmonella,
Brucella, Legionella, Campylobacter, H. influenzae, Lyme
disease)
Mycobacterial infection (M. tuberculosis, M. avium, M.
intracellulare)
 Protozoal and fungal infection
 Rickettsial infection and parasitic infection
 Anaerobic organism (Clostridium, anaerobic Streptococcus)
Imazio M. J Cardiovasc Med (Hagerstown) 2010;11(10):712-722
Etiology of acute pericarditis
Limited dataset (n=386)
1. INFECTIVE:
ADV PCR
ADV SOUTHERN BLOT
 Viral - Positive PCR, in situ-hybridization or a more than 2x viral
titer increase in the serum or the virus is isolated from PE 28 – 34%
 Bacterial - positive bacterial cultures 2 – 3%
 Tuberculosis - Direct microscopy, PCR or culture 6 - 8%
2. NEOPLASTIC - malignant infiltration by cytology or
pathohistology 30-40%
3. IDIOPATHIC - minimal cellularity in PE positive for IgG and
IgA AMLA and ASA antibodies (22-32 %)
Pankuweit, Ristic, Seferovic, Maisch. Am J Cardiovasc Drugs 2005
Bacterial pericarditis
Classification
PURULENT
PERICARDITIS
BACTERIAL
PERICARDITIS
TUBERCULOUS
PERICARDITIS
BACTERIAL
PERICARDITIS
IN AIDS
Pankuweit S, Ristić AD. Am J Cardiovasc Drugs 2005;5(2):103-12
Z. Komosar: Purulent pericarditis (artist’s perspective).
Pericardium is edematous, with abundant fibropurulent viscid
pus, granulation tissue, and loculation.
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p330
Purulent pericarditis
Clinical facts and natural history
 Frequently associated with pneumococcal
pneumonia and meningococcal infection
 Can occur as sporadic cases
(M.pneumoniae , Menigococcus) or
following cardiac surgery (Klebsiella,
Streptococcal Group A & B)
 Infectious etiology changing in recent
decades
 Always fatal if untreated (mortality rate of
~ 40% )
Badawi R et al. Int J Cardiol 2002 82 (2):187-9
Schaumann R et al. Infection 2001; 29 (1): 51-3
Purulent Pericarditis
CONDITIONS PREDISPOSING TO THE
DEVELOPMENT OF THE DISEASE
 Preexisting pericardial
effusion
 Dialysis (e.g. uremic
pericarditis)
 Immunosuppression
(immunotherapy, leukemia,
 AIDS
 Chronic debilitating diseases
(alcohol abuse, ulcerative
colitis)
Spodick DH. New York: Marcel Dekker, 1997: 260-90
Purulent Pericarditis
Pathophysiology
 Direct extension of bacterial
pneumonia (20-25%), empyema or
mediastinitis
 Hematogenous spreading (22-29%)
during generalized sepsis
 Extension from myocardium
(14-22%) or subdiaphragmatic
suppurative foci
 Direct infection after cardiac
surgery (24-29%) and chest trauma
Rubin RH. Am J Med 1975; 59 (1): 68-78
Klacsmann PG. Am J Med 1977; 63: 666-73
Infective endocarditis complicated
by purulent pericarditis
 Micro or overt perforation
 Frequent in
imunocompromised
patients
 Worsening of the clinical
presentation
 Fast progression to fatal
outcome
Keersmaekers T et al. Acta Cardiol 2002; 57 (5): 387-9
Diagnostic approach to pericardial disease
New trends and perspectives
 Doppler echocardiography (TTE, TEE)
 MRI/CT
 Pericardioscopy – in vivo pathology
 Pericardial fluid analyses – in vivo
cytology and microbiology
 Pericardial and epicardial biopsy – in vivo
histology, PCR diagnostics of microbial
agents, in vivo immunohistochemistry
Bacterial pericarditis
Diagnosis
Pericardiocentesis must be
promptly performed
Pericardial fluid should undergo
Gram, acid-fast, and fungal
staining, followed by cultures for
aerobes, anaerobes, and M.
tuberculosis (preferably with
radiometric growth detection).
Drug sensitivity testing is
essential for treatment selection.
Maisch B, Seferović PM et al. Eur Heart J 2004;25(7):587-610
Purulent pericarditis
Pericardial effusion analyses
Should be ordered according to the clinical presentation
• Three cultures of pericardial
fluid and blood for aerobes
and anaerobes
• If positive,culture followed by
sensitivity tests for antibiotics
• PCR analysis, if cultures
negative and for unusual
bacteria
Maisch B, Seferović PM et al. Eur Heart J 2004;25(7):587-610
Bacterial pericardial effusion
50-90% neutrophyles
 Associated with
pneumonia
Purulent pericardial
effusion
>90% neutrophyles
detritus, fibrin
 Various etiologies
Maisch B, Dtsch Med Wochenschr 2006;131(39):2143-6
Purulent pericarditis
Clinical vignettes
Tamponade caused by purulent effusion in
32 yr. old male with insulin-deprendent
diabetes, COPD and meningococcal sepsis
Acute fibrinopurulent pericarditis.
Broad fibrinous network, granulocytic
infiltration and copious dilated blood
vessels (HEx40)
Purulent pericarditis
Management
I.
After identification of causative
microorganism, intravenous
intensive antibiotic therapy
according to antibiogram
II. Urgent pericardial drainage is
indicated
III. Pericardiectomy: is frequently
needed to avoid constriction
•
Intrapericardial instillation of
urokinase or streptokinase is a
therapeutic option
Goodman LJ, Curr Treat Options Cardiovasc Med 2000
Purulent Pericarditis
New treatment options
LUES OF THE PERICARDIUM
(pericardial biopsy) PRESENTING
AS EFFUSIVE-CONSTRICTIVE
PERICARITIS
Z. Komosar: Tuberculous pericarditis (artist’s perspective). Fibrin
covers the edematous pericardial surface, forming thick, shaggy,
villous deposits - “leathery” pericardium. Beneath fibrous deposits,
light grey nodules of granulomatous tissue can be distinguished.
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p.304
Tuberculous pericarditis
Clinical expression
CT of encapsulated
tuberculous pericarditis with
circular organization in 48 yr.
old female, with previous renal
TBC. The density values of the
exudate are 29 HU
 Clinical mimicry: Remarcably variable
clinical manifestations
 Clinical forms:
 Slow (typical) - insidious onset/large
effusions
 Aggressive course (rare) - acute
tamponade
 May erupt despite appropriate
antimicrobial treatment for tuberculosis
elsewhere
 Children and immunocompromised pts
more often present with acute pericarditis
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p330
Tuberculous pericarditis
Clinical vignettes I
Chronic tuberculous pericarditis. Tick
Constrictive pericarditis due to TBC
fibrine deposits covering pericardial
pericarditis. Enlarged heart with straight
surface. Copious tubercles in the
margins, optuse right cardiophrenic angle due
pericardial tissue (HEx10)
to extensive adhesions and left sided pleural
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p.262
effusion
Tuberculous pericarditis
Clinical presentations
Fever of unknown
origin
Toxic symptoms of
chronic systemic illness,
Anorexia and weight
loss
Pulmonary and/or
extrapulmonary
tuberculosis
Kraen M et al. Eur Heart J 2009;30(21):2574.
Tuberculous pericarditis
PERICARDIAL PRESENTATIONS
Pericardial effusion with left
pleural effusion, in 52 yr. old
male with pulmonary TBC.
Calcification typical for TBC
in the right pulmonary apex
Acute pericarditis
with/without effusion
Silent effusion, often large and
chronic
Tamponade, often
asymptomatic, except fever
Effusive-constrictive
pericarditis
Pericardial
constriction/calcifications
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p 305
Tuberculous pericarditis
Predictors of constriction
Right sided PE or chronic
cardiac tamponade (Suwan
Br Heart J ´95)
High adenosine deaminase
(Komsuoglu EHJ ´95).
Pericardial calcification indicate chronic pericarditis,
rarely constriction
Komsuoğlu B. Eur Heart J 1995;16(8):1126-30.
Tuberculous pericarditis
Pericardial effusion analyses
 The diagnostic yield of pericardiocenthesis
is 30-70%
 Features of TBC pericardial effusion:
 High specific gravity
 High protein level
 High white cell count (mean 7.8x109/L)
 Positive Ziehl Nielsen staining exceptionally
Clusters of slim, red beaded
low
rods representing
tuberculous bacilli
 The culture of TBC bacilli in Lowenstein(Ziehl Nielsen x 40)
Jensen medium slow
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p. 23
Tuberculous pericarditis
Clinical vignettes II
Microvoltage and pulsus alternans due to
sudden onset cardiac tamponade , in 62 yr. old
male with lupus erithematodes and TBC
pericarditis
TBC pericarditis. Pericardial biopsy
demonstrating conglomerates of
tubercles consisting of aggregated
epitheloid cells and occasional Langhans
giant cells, rimmed by lymphocytes
(HEx40)
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p.262
Tuberculous pericarditis
Diagnostic tests
PCR analyses
Adenosine deaminase >40 IU/L
Interferon-gamma >200 pg/L
Pericardial lysozyme >6.5
microg/dL
Cost-effective only if the pre-test probability is
high (high incidence of tuberculosis)
Kobashi Y et al. Scand J Infect Dis 2010;42(9):712-5
MACROSCOPIC
PERICARDIOSCOPY FINDINGS
(Seferovic PM, et al. Herz 2000, Circulation 2003)
all p>0.05
Tuberculous pericarditis
The role of pericardioscopy and
pericardial biopsy
Pericardioscopy in tuberculous pericarditis.
Detailed technical description of the procedure (far
left). Extensive hyperemia and focal erosive lesions
on the visceral pericardium (left) and vascular
injection with extensive band-like protrusions on
the parietal pericardium (right)
Seferović PM et al. Pericardiology. Nauka, Beograd 2000; p.308
The complexites of diagnosis
of tuberculous pericarditis
Tuberculous pericarditis
Management
 Respiratory isolation in active laryngeal or lung TBC
 The initial treatment:
–
–
–
–
–
Isoniazid 300 mg/day
Rifampicin 600 mg/day
Pyrazinamide 15-30 mg/kg/day
Ethambutol 15-25 mg/kg/day.
Prednisone (1-2 mg/kg/day) may be given
simultaneously with antituberculous therapy for 5-7
days and progressively reduced to discontinuation
in 6-8 weeks.
 After two months most patients can be switched to
two-drug regimen (isoniazid and rifampicin) for the
total of 6 months.
Brondex A. Ann Cardiol Angeiol (Paris) 2010.
Tuberculous Pericarditis
Adjunctive prednisolone vs. placebo in
TBC pericarditis in HIV+ patients
 58 HIV pts aged 18-55 yrs with TBC
pericarditis in Zimbabwe treated with
pericardiocentesis+ standard short course
antituberculous chemotherapy + prednisolone
or placebo for six weeks.
 Mortality (18 months follow-up) significantly
lower in prednisolone group (17.2% vs.
34.5%; p = 0.004).
Hakim et al. Heart 2000; 84(2): 183–188.
 In prednisolone group decreased jugular
venous pressure (p = 0.017), hepatomegaly (p
= 0.007) and ascites (p = 0.015).
 Prompt treatment prevent constriction in
>50% of the pts.
Bacterial pericarditis in AIDS
 Bacterial pericardial infection more frequent
(23%) usually by multiple organisms
 Incidence of echocardiographically confirmed
pericardial effusion 40%
 High proportion of M. avium-intracelulare,
M. tuberculosis ans S. Aureus infections
 Clinical coexistence of AIDS and tuberculosis
often
 Rapid TBC resolution if AIDS treated
sucessfully
Silva-Cardoso J et al. Chest 1999; 115: 418-22
PURULENT PERICARDITIS ASSOCIATED WITH
KAPOSI SARCOMA OF THE PERICARDIUM AND AIDS
Bacterial infections of the myocardium and pericardium
Conclusions I
 The identification of etiological bacterial
agents and early treatment is essential for the
successful treatment and patients recovery
 Myocardial purulent bacterial infections are
rare, often clinically unrecognized, appearing
in acute and fulminant forms and have
associated with high mortality
 Lyme myocarditis is transient myocardial
inflammation, clinically presented as variable
degrees of atrio-ventricular block and
syncope, successfully treated with antibiotics
Bacterial infections of the myocardium and pericardium
Conclusions II
 Purulent pericarditis is rare, but serious
clinical condition with high mortality, which
can be successfully treated with early
pericardial drainage, intravenous antibiotics
and pericardiotomy
 Tuberculous pericarditis is always associated
with TBC process elsewhere, presenting
often with severe constitutional symptoms
and various pericardial manifestations,
including constriction. New biochemical tests
and pericardioscopy are essential for
diagnosis
Medical decisions were always tough to make