Mediastinitis: An Unusual Cause of Pericarditis

A 34-year-old man is admitted to the hematology ward for severe vomiting and dysphagia, develops severe pleuritic chest pain 4 days after admission.

His medical history is significant for HIV infection diagnosed concurrently with diffuse large B-cell lymphoma (DLBCL) in 2017. He was maintained on Highly Active AntiRetroviral Therapy (HAART) and failed multiple lines of treatment for DLBCL. In that context, he underwent stem cell transplant 48 days prior to assessment. Post-transplant, he developed cutaneous graft versus host disease (GVHD) and was maintained on therapeutic level of immunosuppressive drugs.

Upon admission, the patient was hemodynamically stable but found to be in acute kidney injury thought to be secondary to dehydration. An esophageoduodenoscopy (EGD) was performed to eliminate the possibility of an opportunistic infection explaining his gastrointestinal (GI) symptoms. EGD demonstrated duodenitis but no biopsies were taken as the patient was very agitated throughout the procedure. A repeat EGD was performed 2 days later for biopsies to rule out GVHD.

At the time of assessment, the patient reported a 3-day history of sharp pleuritic chest pain radiating to the back, worsening in the supine position. This pain started 2 days after the first EGD. He denied any associated cough, diaphoresis, palpitations, fever or chills. He did report worsening of longstanding shortness of breath on exertion, present since the stem cell transplant, but denied orthopnea or paroxysmal nocturnal dyspnea.

His resting blood pressure was 116/76 mm Hg with a pulse of 100 beats per minute. He was afebrile and saturating 92% on room air. On exam, he was tachypneic but in no acute distress. There were no distant heart sounds or pericardial friction rub. His jugular veins were not elevated and demonstrated normal variation with respiration. There was no leg edema.

Available laboratory work-up revealed normal electrolytes with a creatinine 154 mmol/L (from 224 mmol/L, normal range 74-107 mmol/L), white blood cell count 4,9 X 109/L, hemoglobin 75 g/L (normal range 120-150 g/L) and platelets 61 X 109/L (at baseline), C-reactive protein 90 mg/L (from 18 mg/L). CD4 count dropped to 48 cells/µL, with CMV PCR negative.

The electrocardiogram (ECG) was unremarkable (Figure 1A).

A transthoracic echocardiogram performed to evaluate his dyspnea and chest pain was significant for a small circumferential pericardial effusion, without chamber collapse, and plethoric IVC suggestive of high right-sided pressures with no frank evidence of tamponade or constrictive physiology (Figure 1B).

A chest computed tomography (CT) scan with contrast was also performed to investigate the patient's dyspnea. It was notable for diffuse pericardial and epicardial fat stranding with mild pericardial collection and enhancement of the pericardium (Figure 1D), highly suspicious for infectious mediastinitis. There was no pneumomediastinum and moderate pleural effusions were noted bilaterally.

Figure 1

Figure 1
Figure 1. A. Patient's ECG showing normal sinus rhythm, without any changes suggestive of pericarditis B. Echocardiography (subcostal view) showing small circumferential pericardial effusion, measured at most 8 mm over the right ventricle. C. Axial chest CT performed 5 months before presentation showing normal pericardium and a small loculated pericardial effusion (arrow). D. Axial chest CT during hospitalization showing thickening of the parietal pericardium (arrow), diffuse pericardial and epicardial fat stranding (arrowhead), bilateral pleural effusion (*), and a small pericardial effusion (◇).

The possibility of infectious mediastinitis raised the concern for a micro-perforation post-endoscopy given the agitation of the patient during the procedure, but it was judged less likely by the infectious disease specialists. Antibiotics were started nonetheless given the fragility of the patient, and thoracentesis was performed.

Given the new pericardial effusion, typical positional pleuritic chest pain and findings of pericardial fat stranding on CT, the patient was diagnosed with acute pericarditis likely related to contiguous inflammation from the mediastinum.

What would be the most appropriate treatment for this patient's pericarditis?

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