Treatment:
The patient underwent pericardiocentesis then laparoscopic drainage of
her perihepatic abscesses and drain placement with extensive hepatic
necrosis noted intraoperatively. She improved clinically and was
discharged with ampicillin-sulbactam and doxycycline for a total of
eight weeks of antibiotic therapy.
Outcomes and Follow-Up:
She was seen once more in the Infectious Disease clinic and was
asymptomatic. She was then lost to follow up before being seen by OB-GYN
for evaluation of the tubo-ovarian abscess.
Discussion:
Fusobacteria are an obligate anaerobic, non-spore forming, Gram-negative
bacilli that are considered normal flora in the oral cavity. This
organism accounts for less than 1% of bacteremia and less than 1% of
clinically significant infections (1).Fusobacterium nucleatum is at times a difficult organism to
isolate in clinical practice where the bacterium is not easily grown in
blood or abscess cultures, but only on PCR or other modalities
(12).
As in the case above with only the liver aspirate culture with positive
growth, patients may present with disseminated infections and have
abscesses in multiple organs despite most of the cultures remaining
negative. One contributing factor to this culture negativity would be
ample pre-culture antibiotics. Although there was no confirmed source
for this case’s infection, we assume it was from poor dental hygiene and
social history.
Pyogenic liver abscesses (PLA) are the most common form of liver abscess
in the United States and are most frequently caused by E. coli in
adults. Fusobacterium nucleatum has rarely been reported as a
cause of PLA, and to our knowledge, there is only one other reported
case of Fusobacterium PLA associated with pericardial effusion
(12).
Cardiac tamponade (CT) is defined as compression of the cardiac chambers
due to an increase in intrapericardial pressure. This may be due to
accumulation of fluid, pus, blood, clots, or gas within the pericardial
space as a result of an effusion, trauma, or rupture of the myocardium
(13). While the pericardium does have
some degree of elasticity, a rapid accumulation of fluid will lead to a
marked increase in intrapericardial pressure that may impede normal
cardiac filling and result in cardiovascular collapse. Beck’s triad of
hypotension, elevated jugular venous pressure, and muffled heart sounds
are the classic presentation of acute CT. However, these features are
not always present, especially in subacute tamponade as in our patient.
Additional clinical diagnostic factors include tachycardia and pulsus
paradoxus. Prompt diagnosis and assessment of acute or subacute CT
should be aided by TTE.
There are many echocardiographic signs of CT in addition to the presence
of a pericardial effusion. The most sensitive findings include collapse
of the right atrium (RA) or right ventricle (RV) and inferior vena cava
plethora. Left atrial collapse is also highly specific, but only seen in
approximately 25% of hemodynamically compromised patients
(14). Additionally, there may be changes
in right and left-sided inflow velocities with respiration. Tricuspid E
wave velocity variation >60% and mitral E wave velocity
variation of >25% by pulsed-wave doppler is highly
suggestive of CT (14).
In regards to etiology, infection is a less common cause of tamponade.
Multiple studies have demonstrated a rate of 15-24%, however these
infections are predominately viral, with bacteria accounting for
approximately 3.7% of total cases (15).
Common bacteria to cause tamponade include Staphylococcus,
Streptococcus, Escherichia coli, Salmonella , and Neisseria
meningitides (16). However, despite
extensive literature review, we were unable to find a case of a
Fusobacterium infection causing tamponade, nor any bacterial liver
abscess invading into the pericardium causing tamponade physiology.
Furthermore, this may be the first documented case of a tubo-ovarian
abscess (TOA) caused by F. nucleatum. While there are two case
reports of TOA caused by F. necrophorum(14,15)
there are no published cases of TOA caused by this species of
Fusobacterium.
In conclusion, maintaining a broad differential diagnosis during unique
clinical presentations is prudent. Fusobacterium nucleatum is
considered normal flora in the oral cavity, but when it rarely causes
clinically symptomatic infection, its presentation varies widely. In
this case, rapid identification of an exceedingly rare and possibly
novel case of Fusobacterium nucleatum infection prevented grave
hemodynamic collapse in the setting of sub-acute cardiac tamponade and
yielded a favorable outcome.
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Learning Points:
- To appreciate that Fusobacterium spp. should be on the differential
for any organ abscess in an immunocompromised patient, especially when
there are multiple sites of infection, including but not limited to,
the liver, brain, or lungs.
- To understand that for any case of Fusobacterium spp. infection, the
most common source is oral/periodontal flora, especially in patients
with poor dental hygiene.
- To understand that Fusobacterium spp. is difficult to grow in culture.
- To understand the etiologies, clinical presentation, and imaging
findings associated with cardiac tamponade.
- To consider repeat imaging following completion of treatment regimen
to ensure improvement or resolution of infection given the microbe’s
tendency to seed various organ systems.