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.