Cox, Frank, Jr.

Fisher, Evelyn J.

Madhavan, T.

Quinn, Edward L.

English

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Henry Ford Hospital Medical JournalVolume 21 | Number 1 Article 63-1973Concomitant Streptococcal Endocarditis andTuberculous Pleuro-Pericardial EffusionT. MadhavanEvelyn J. FisherFrank Cox Jr.Edward L. QuinnFollow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public HealthCommonsThis Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.Recommended CitationMadhavan, T.; Fisher, Evelyn J.; Cox, Frank Jr.; and Quinn, Edward L. (1973) "Concomitant Streptococcal Endocarditis andTuberculous Pleuro-Pericardial Effusion," Henry Ford Hospital Medical Journal : Vol. 21 : No. 1 , 39-42.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol21/iss1/6Henry Ford Hosp. Med. Journal Vol. 21, No. 1, 1973 NOTES AND COMMENTS Concomitant Streptococcal Endocarditis and Tuberculous Pleuro-Pericardial Effusion T. Madhavan, MD* ; Evelyn ). Fisher, MD*; Frank Cox Jr., MD*, and Edward L. Quinn, MD* ** / A young adult heroin addict wi th S t rep tococcus v i r idans e n d o c a r d i t i s developed the unusual compl icat ion of massive pericardial and pleural effusion which was shown to be due to concomi-tant t u b e r c u l o s i s . In a d d i t i o n , his course was complicated by a hemiplegia secondary to ruptured cerebral mycotic aneurysm treated neurosurgical ly w i t h complete recovery. Since these mul t ip le p r o b l e m s w e r e reso lved by spec i f i c d iagnosis and app l i ca t ion of medica l and surgical techniques now available, the patient is made the subject of this report. 'Division of Infectious Diseases, Department of Medicine. "Clinical professor of Medicine, Univ. of Mich. Medical School. Address reprint requests to Dr. Madhavan, Division of Infectious Diseases, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, Ml 48202 Case Report A 23-year old Negro male was admitted to the hospital on September 11, 1971 with complaints of cough, dyspnea, yellow sputum, palpitat ions, night sweats and anorexia. He was a known narcotic addict, who had been using intravenous heroin for two years prior to admission. Physical exami-nation revealed a low grade fever, poor oral hygiene, apical systolic thr i l l , apical Grade IV/VI holosystolic murmur, hepatomegaly and subungual splinter hemorrhages. On admission, his hemoglobin was 10.4 grams% and white blood cell count was 13,500 cells/cmm. Urine analysis, serum elec-trolytes, creatinine, serum enzymes, proteins blood urea nitrogen, blood sugar and test for Australia antigen gave normal results. Reticulocyte count was 2.7%, and hemoglo-bin electrophoresis revealed 60% hemoglo-bin A and 40% hemoglobin S. Purified pro-tein derivative (PPD)-S and B skin tests were negative. Admission chest x-ray was unremarkable (Figure 1). Serum IgG was 2005 mg%. Six admission blood cultures grew alpha hemolytic streptococci sensitive to all the antibiotics tested. The patient was given intramuscular Clindamycin 450 mg every 8 hours with good response. 39 Madhavan, Fisher, Cox and Quinn i Figure 1 Normal chest film on admission. Figure 2 Film of chest demonstrating enlarged heart, plethoric lung fields and right pleural effusion. On September 19th, patient developed anterior substernal chest pain and progres-sive dyspnea. Heart was found to be enlarged and a pericardial rub was heard. An electrocardiogram was consistent wi th pericarditis. On September 21st, a pericar-diocentesis was performed and 100 cc of serosanguinous f lu id was aspirated with immediate improvement in his clinical con-dition. The pericardial fluid contained 70 mg of glucose/100 ml, 4.9 gms of proteins/100 ml with 3500 cells, mostly polymorphonuclear leucocytes. A left sided pleural effusion was also detected and tapped. The pleural fluid yielded positive smears and cultures for mycobacterium tuberculosis (human type). Pleural biopsy revealed granuloma with acid fast bacilli. Pericardial fluid was negative for acid fast bacill i on smear and culture. Antituberculous therapy was initiated with isoniazid, streptomycin, and ethambutol. Management also included digitalization and diuretics. On October 11th, the patient's clinical condition again deteriorated. He was found comatose and convulsing with right hemi-plegia and complete heart'block. A temporary transvenous pacemaker was inserted and tracheostomy was performed. Based on arteriogram, diagnosis was made of left tem-poral hematoma presumably secondary to ruptured cerebral mycotic aneurysm. A left temporal craniotomy and evacuation of the clot resulted in gradual recovery. Follow-up brain scan was negative. On November 5th, chest x-ray was reported normal with normal heart size (Figure 3). His PPD-S and B continued to be negative. The patient was discharged on January 27, 1972 with residual right hemi-plegia. Follow-up in the outpatient clinic in the next ten months revealed recovery was complete, except for a residual Grade IV/VI apical systolic murmur, and apical S3 gallop and right inferior quadrantanopsia. Discussion Small pericardial effusions have been reported to occur in some cases of sub-acute bacterial endocarditis, but mas-sive nonsanguineous pericardial effu-40 Endocarditis with Effusion Figure 3 Normal heart size, as shown by chest fi lm. effusion by isolation of tubercle bacill i f r o m the p leura l f l u i d . H o w e v e r , t he smears and cu l tures of the pericardial f lu id were negative. This association of Streptococcus viridans endocardit is and tuberculous pleuro-pericardial effusion has no t been p rev ious l y r e p o r t e d in English l i terature. Cerebral mycotic aneurysms are usu-ally asymptomatic until they rupture and prognosis in the patient wi th ruptured myco t i c aneurysm is usual ly p o o r . A high index of suspicion, p rompt diag-nosis w i t h repea ted n e u r o l o g i c a l examinat ion, angiography and early sur-gical in tervent ion leading to comple te recovery have been r e p o r t e d in a number of cases in recent years. sion is a rare occurence ^'^ Tykot and Relkin reported one patient wi th Strep-tococcus v i r idans e n d o c a r d i t i s w h o developed massive pericardial ef fusion of unknown cause wi th cardiac tam-ponade .Th i s pa t i en t r e q u i r e d t h ree pericardiocenteses before he recov-ered.'* Large pericardial effusion can also be a complicat ion of a myocardial mycotic aneurysm or mycotic aneurysm involving the coronary cusps.'-" In our patient, we demonstrated the probable tubercu lous et io logy of the pericardial Summary A case is described of Streptococcus v i r idans endocard i t i s w i t h an unusual c o m p l i c a t i o n of massive t u b e r c u l o u s p l e u r o - p e r i c a r d i a l e f f u s i o n . The patient's hospital course was also com-pl icated by a hemip leg ia secondary to r u p t u r e d cerebra l myco t i c aneurysm. This was t r e a t e d by le f t t e m p o r a l craniotomy and clot evacuation, result-ing in excellent recovery. References 1. Holt E: Valvular disease of heart; pur-pura hemorrhagica; malarial fever; sub-acute rheumatism. Complications by pericarditis with effusion, and this by pneumonia - all occurring within period of 8 months, with ultimate recovery. Arch Pediat 51:126-9,1934 2. Musser JH: Clinic of Dr. John H. Musser, Med Clin N Amer 3:1408-16, 1920 3. Mayer ED: Pericarditis complicating sub-acute bacterial endocarditis. I Mich Med Soc 35:219-222, 1936 4. Beck D: Pericarditis and subacute bacter-ial endocarditis. J Mount Sinai Hosp NY 8:364-75, 1942 5. Blumer G: Subacute bacterial endocar-ditis. Medicine (Bait) 2:105-170, 1923 41 Madhaven, Fisher, Cox, and Quinn 6. Tykot HB, Rilkin R: Massive pericardial effusion in subacute bacterial endocar-ditis. yAMA 184:898-900, 1963 7. Case records of the Massachusetts General Hospital (Case 2-1970). New Eng I Med 282:90-6, 1970 8. Case records of the Massachusetts General Hospital (Case 46-1970). New Eng I Med 283:1042-50, 1970 9. Roach MR, Drake CG: Ruptured cerebral aneurysms caused by microorganisms. New Eng J Med 273:240, 1965 10. Bawa YS, Wahi PL: Subacute bacterial endocarditis: meningeal complications. Texas Med 57:159, 1961 11. Bell WE, Butler C: Cerebral mycotic aneurysms in children. Neurology 18:81, 1968 12. Campbell E, Burkland CW: Aneurysms of the middle cerebral artery. Ann Surg 137:18, 1953 14. King AB: Successful surgical treatment of an intracranial mycotic aneurysm com-plicated by subdural hematoma. J Neurosurg 17:788, 1960 15. Mukerji KC, Parulkar GB: Mycotic aneurysm: a case report. Indian I Med Sc 16:1063, 1962 16. Shnider Bl, Cotsonas NJ: Embolic myco-tic aneurysms: a complication of bacter-ial endocarditis. Amer / Med 16:246,1954 17. Starrs RA: Subacute bacterial endocar-ditis presenting as a subarachnoid hemorrhage: report of a case with recovery. Ann Intern Med 31:139, 1949 18. Whipple RL, j r : Subacute bacterial endocarditis presenting as a sub-arachnoid hemorrhage: report of a case with recovery. Ann Intern Med 35:1351, 1951 13. Graves PR, Brodie I j : Recovery from a ruptured mycotic aneurysm. Brit Med J 1:786, 1950 19. Hurxthal LM: Clinical observations on subacute bacterial endocarditis. New Eng J Med 220:587, 1927 42 

Concomitant Streptococcal Endocarditis and Tuberculous Pleuro-Pericardial Effusion

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Concomitant Streptococcal Endocarditis and Tuberculous Pleuro-Pericardial Effusion

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