Accepted Manuscript

A Case Study of Mycobacterium Avium Complex Infection Presenting with AcutePericarditis

Robert S. Moskowitz, MD FACP Rebecca Brickman, RN CCRN Chaim Moeller, MD

PII: S0002-9343(14)00268-X

DOI: 10.1016/j.amjmed.2014.03.014

Reference: AJM 12452

To appear in: The American Journal of Medicine

Received Date: 19 December 2013

Revised Date: 11 March 2014

Accepted Date: 11 March 2014

Please cite this article as: Moskowitz RS, Brickman R, Moeller C, A Case Study of MycobacteriumAvium Complex Infection Presenting with Acute Pericarditis, The American Journal of Medicine (2014),doi: 10.1016/j.amjmed.2014.03.014.

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A Case Study of Mycobacterium Avium Complex Infection Presenting with Acute Pericarditis

Robert S. Moskowitz, MD FACP

Rebecca Brickman, RN CCRN

Chaim Moeller, MD

Maimonides Medical Center, Brooklyn, New York

Corresponding Author:

Robert S. Moskowitz

325 Buchanan Ave.

Staten Island, New York 10314

Email:rmosko@juno.com

Funding Source: None

Conflict of Interest: Robert Moskowitz-None

Rebecca Brickman-None

Chaim Moeller-None

All authors had access to data in article and were involved in writing the article.

Article Type: Case Report

Key Words: Myobacterium avium complex infection acute pericarditis

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Robert S. Moskowitz, MD FACP

Rebecca Brickman, RN CCRN

Chaim Moeller, MD

Maimonides Medical Center, Brooklyn, New York

A Case Study of Mycobacterium avium complex infection presenting with acute pericarditis.

Abstract:

Mycobacterium avium complex infections are most commonly found in the lungs specifically in

immunocompromised patients. We describe a 73 year old male with no past medical history with

mycobacterium avium complex infection presenting with acute pericarditis.

Introduction:

Mycobacterium avium complex infections are a category of non-tuberculosis mycobacterium infection

that causes diseases of the lungs. Mycobacterium avium complex infections usually presents in patients

white, middle to older age, men who are alcoholics or smokers with underlying obstructive pulmonary

disorders.1 Patients present with fever, sweats, fatigue, weight loss and diarrhea.

Case Report:

73 year old male presented to the emergency department with shortness of breath and chest pain

specifically on inspiration. He was a retired plumber who never smoked and only past medical history

included diverticulosis.

On physical examination his oral temperature was 100.8F, respiratory rate 19bpm, pulse rate 113bpm

and blood pressure 143/72. His lungs were clear and he had no cardiac gallop murmurs or rubs. His

abdomen was benign and he had no pedal edema.

His electrocardiogram showed diffuse mild ST elevations in anterior and inferior leads. Initial lab results

for brain natriuretic protein, CKMB, myoglobin and troponin were all normal. White blood count was

elevated at 15.5k/ul and d-dimer plasma assay elevated at 861mcg/L.

A chest x-ray (Figure 1) found no focal infiltrates or effusions. Patient was tested negative for human

immunodeficiency virus.

CT scan (Figure 2) showed moderate pericardial effusion up to 15mm maximal thickness and bibasilar

minimal to moderate atelectasis, with a small left effusion.

Echocardiogram revealed moderate circumferential pericardial effusion, right atrial and right ventricular

collapse consistent with cardiac tamponade. There was no evidence of valvular disease but there was

mild left ventricular diastolic dysfunction with an ejection fraction of 55%.

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A Case Study of Mycobacterium Avium Complex Infection Presenting with Acute Pericarditis

Patient was taken to the operating room, 400ml pericardial fluid was drained and a quarter size segment

of pericardium was excised and sent to pathology. The fluid had 9450 white blood cells/ul (94%

neutrophils) and 11,000 red blood cells/ul.

Post surgical echo revealed resolved pericardial effusion with an ejection fraction of 65%. The patient

went home a day after the procedure.

An acid fast bacillus culture from the pericardial fluid specimen showed positive mycobacterium avium-

intracellular complex by DNA accuprobe. His skin purified protein derivative test was markedly positive.

The patient was informed of the results of the acid fast bacillus culture but refused antimicrobial

medications. The patient was treated with non steroidal anti-inflammatory agent but stopped it and had

a recurrence three weeks after discharge. He restarted the anti-inflammatory agent and never had any

recurrence over the next year.

Discussion:

This case study was intriguing. Firstly the mycobacterium avium complexes were found in the

pericardium, and it was only discovered when the patient presented with pericardial tamponade,

otherwise the infection may have gone undetected. Additionally, the patient was human

immunodeficiency virus negative. The majority of patients with mycobacterium avium complex

pericardial infections are immunocomprimised patients with human immunodeficiency virus.

Another point to ponder is where this patient contracted the disease, as mycobacterium avium complex

is not contagious from person to person. Could he have acquired it while performing plumbing, since

mycobacterium avium complexes can be found in soil and water, or did he pick up the disease

elsewhere?

This is the third case report of mycobacterium avium complex in an immunocompetent host presenting

with acute pericarditis.1,2 Our patient had no evidence of pulmonary disease and no further recurrence

of his symptoms despite never receiving antimicrobial treatment.

References:

1. Marvisi M, Bassi E, Zanlari L, Civardi G. A case of mycobacterium avium complex infection in an

immunocompetent man presenting with pericarditis and an HRCT pattern of lymphangitis. Eur J Int Med

2008; 19:300-2.

2. Corey R, Campbell PT, Van Trigt P, Kenney RT, O’conner CM, Sheikh KH, et al. Etiology of large

pericardial effusions. Am J Med 1993; 95:209-13.

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