Capnocytophaga Induced Acute Necrotizing and Exudative Pericarditis with Abscess Formation
Capnocytophaga Induced Acute Necrotizing and Exudative Pericarditis with Abscess Formation
Alexa Bello 1 2
Alejandro Castaneda 0 1
Abhay Vakil 4
Salim Surani 5
0 Universidad Autonoma de Baja California , Houston, TX , USA
1 Dorrington Medical Associates , Houston, TX , USA
2 Universidad Popular Autonoma del Estado de Puebla , Puebla, PUE , Mexico
3 United Memorial Medical Center , Houston, TX , USA
4 University of North Texas , Denton, TX , USA
5 Division of Pulmonary, Critical Care & Sleep Medicine, Health Science Center, Texas A&M University , Corpus Christi, TX , USA
We present the case of a 55-year-old gentleman, with bilateral pulmonary embolism and a large pericardial effusion that lead to a pericardial window with evacuation of creamy pus. Gram stains were negative, with culture growing Capnocytophaga. Pathology revealed acute necrotizing and exudative changes, including frank abscess formation. In developed countries, pericardial abscess and acute pericarditis are uncommon due to availability of broad-spectrum antibiotics. Pericardial abscess due to Capnocytophaga is even more uncommon.
Acute pericarditis (AP) represents nearly 0.1% of the
diagnoses of patients being hospitalized for acute chest pain
not related to myocardial infarction and nearly 5% of
the diagnoses in the emergency department [
AP is common, its treatment represents a challenge due
to delays in diagnosis, which increases the complications
]. Recurrences have been reported in nearly 30% of
the patients who have experienced AP . Acute pericarditis
can be caused by infectious and noninfectious etiologies
]. In developed countries, purulent bacterial pericarditis
is less frequent due to the availability of broad-spectrum
antibiotics . We present a case of purulent pericarditis
with necrotizing and exudative changes leading to cardiac
2. Case Presentation
A 55-year-old gentleman with a history of diabetes
mellitus, hypertension, cocaine, and marijuana use presented
to the emergency department (ED) with complains of chest
pain and dyspnea for past 6–8 months, as well as lower
extremity edema and weight loss. On admission to the
hospital, his vital signs were stable. Physical examination
revealed obesity, decreased breath sounds bilaterally, and
mild tachycardia, and point of maximal impulse was
enlarged and displaced at the presence of edema on bilateral
lower extremities. )e patient has poor dentition with
cavity in the left second molar tooth. )e rest of the
examination was otherwise unremarkable. Complete blood
count revealed a hematocrit of 33.1%, hemoglobin 9.7 g/dL,
platelet count 232,000/mL, and white blood count 8.6 × 103.
Blood chemistry was unremarkable. B-type natriuretic
peptide was 613 pg/mL.
Because of his chest pain and associated signs, the patient
underwent a computed tomography (CT) scan of the chest
with intravenous contrast, which revealed a very large
pericardial effusion, compressing the right and left ventricles
and the right atrium (Figure 1). In addition, there was
consolidation in the left mid lung, bilateral pleural effusions,
and bilateral pulmonary embolism. A 2D echocardiogram
revealed cardiac tamponade with right ventricular diastolic
collapse, with a large fibrinous exudative pericardial effusion
(Figure 2). )e patient underwent an emergent pericardial
window due to his clinical signs and symptoms consistent
with cardiac tamponade. )e pericardial drainage showed
a significant amount of yellow creamy pus with thickened
pericardium. Anaerobic culture reported the presence of
Capnocytophaga species. )e pathology specimen showed
acute necrotizing and exudative changes including frank
abscess formation with no specific organism detected and no
evidence of malignancy (Figures 3(a) and 3(b)).
)e patient’s condition improved postoperatively and
was placed on piperacillin and tazobactam for four weeks.
His pulmonary embolism and acute deep vein thrombosis
were treated with systemic anticoagulation. )e patient
was discharged home on apixaban and has been seen on
the follow-up visit with significant improvement in his
Acute pericarditis remains a common condition in patients
seen in the ED with a chief complaint of chest pain unrelated
to myocardial infarction [
]. )is entity results from
inflammation of the pericardium, a fibrous tissue that
surrounds the heart and the roots of the great blood vessels
]. Early recognition of AP is important in order to
improve outcome for patients . Due to its clinical
similarity with various acute coronary syndromes and
pulmonary embolism, early recognition is often dismissed [
When clinically recognizable, the symptomatology of AP
mainly includes central and pleuritic chest pain and sharp
retrosternal pain with common characteristics such as
irradiation to one or both trapezius ridges, neck, jaw, or arms
imitating myocardial ischemia with various degrees of
]. In addition, other manifestations include the
presence of pericardial friction rub, pericardial effusion, and
widespread ST elevation or PR depression in the
electrocardiogram . If this condition worsens, the syndrome may
result in cardiac tamponade with subsequent constrictive
In this case, the patient was found to have AP as well as
imaging findings. Chest CT showed a large pericardial
effusion that was compressing the ventricles and the right
Our patient grew Capnocytophaga. )e genus
Capnocytophaga was first described in 1979 by Leadbetter and
]. It belongs to the family Flavobacteriaceae and
the phylum Bacteroidetes [
]. It is found in the oral flora of
humans and animals [
]. )is genus has 9 species, 7 of
them (i.e., C. gingivalis, C. granulosa, C. haemolytica, C.
leadbetteri, C. ochracea, C. sputigena, and Capnocytophaga
genospecies AHN8471) are part of the commensal bacteria
in the oral flora of humans, which are capable of causing
sepsis in immunocompromised patients . C. canimorsus
and C. cynodegmi are found mostly in the bacterial oral flora
of dogs and cats [
In our patient, there was no history of recent animal bite.
His sepsis was due to immunocompromise. Studies have
shown that Capnocytophaga bacteremia is associated with
severe oral pathology and neutropenia, which can also result
in abscess, fulminant sepsis, lung abscess, endocarditis, and
]. Mortality reaching up to 30% for
septicemia and approximately 5% for meningitis has been
)e identification of Capnocytophaga species is difficult
except by DNA hybridization [
]. )is genus is not
detected by the innate immune system; therefore, a
proinflammatory response is not initiated, which results in the
inability of toll-like receptor 4 to respond to
Capnocytophaga. In addition, interleukin-6, interleukin-8, nitric
oxide, tumor necrosis factor-a, and other proinflammatory
cytokines are absent [
]. )e inability of complement
killing as well as to polymorphonuclear-mediated
phagocytosis of this genus leads to a rapid multiplication that can
cause general sepsis, as seen in our patient, or deadly shock
if not treated correctly [
)e first-line treatment for this clinical entity is
penicillin, followed by amoxicillin-clavulanate or third
generation cephalosporin. However, antibiotics such as imipenem,
clindamycin, and doxycycline have also shown clinical
]. Our patient was maintained on piperacillin and
tazobactam rather than switching to penicillin as he was
responding to the therapy adequately.
An early diagnosis and approach for AP benefits the
outcome of patients avoiding complications. In our case, acute
necrotizing purulent pericarditis induced by
Capnocytophaga species was successfully treated.
Conflicts of Interest
)e authors declare that they have no conflicts of interest.
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