CASE PRESENTATION
A man in his early 80’s was rushed to our hospital because he had been
experiencing dyspnea since morning that also showed tendencies toward a
worsening condition. He had bradycardia at admission, and
electrocardiography (ECG) showed ST-segment elevation in leads II, III,
and aVF (Figure 1). Before admission, there were no symptoms of the
common cold, such as fever, and no fever was noted at admission.
Echocardiography showed the absence of pericardial fluid. The patient
had a history of type II diabetes mellitus, hypertension, and
dyslipidemia. With increased levels of biochemical markers of myocardial
injury, the patient was diagnosed with acute myocardial infarction and
underwent emergency cardiac catheterization.
On the second day after the acute myocardial infarction, the patient was
hypotensive, and echocardiography showed cardiac tamponade with an
additional increase in pericardial fluid. Because of a decrease in blood
pressure, shock, and a decreased level of consciousness, we performed
endotracheal intubation. Blood tests showed a C-reactive protein (CRP)
level of 30.18 mg/mL and a white blood cell count of 3,600/μL. Computed
tomography (CT) also showed pericardial effusion (Figure 2), and cardiac
rupture after myocardial infarction was suspected. There was no
suspicion of aortic dissection.
Temporary pacing was initiated for bradycardia. The right coronary
artery was obstructed, and catheterization was performed (Figure 3).
After treatment, the bradycardia improved.
On the night following treatment, fever and tachypnea were observed, and
his respiratory status became poor. On the morning of the second day of
treatment, the patient’s respiratory status further worsened, and
echocardiography showed pericardial effusion, which was not present
before catheterization.
Because of the possibility of pericardial rupture after an acute
myocardial infarction, a median sternotomy, as well as pericardial
drainage and hemostasis, were performed. A pericardial hematoma was
found in the perfusion zone of the right coronary artery, but there was
no obvious pericardial rupture. The pericardial fluid was white and
cloudy, and non-bloody. Infection was suspected, and the generous
irrigation was applied with saline solution. A drain was placed, and the
chest was closed.
The patient was then placed on a drain and returned to the intensive
care unit. After returning to the room, the patient’s shock remained
prolonged, and he was managed with hypertensive drugs.
The shock was not alleviated after surgery and continued for a
considerable time. A large amount of catecholamine was used, antibiotics
were administered, endotoxin adsorption was performed, and the blood
pressure was temporarily elevated. However, the blood pressure rapidly
decreased the day after surgery, and the patient died.
Methicillin-sensitive Staphylococcus aureus (MSSA) was detected
in the blood culture and pericardial fluid. Mycobacterium tuberculosis
culture was negative.