Oesophagopericardial fistula from mediastinal histoplasmosis presenting as purulent pericarditis with cardiac tamponade

A man in his early 30s presenting with chest pain was admitted for the management of acute pericarditis and evaluation of a subcarinal mass incidentally noted on chest imaging. Shortly after admission, he developed cardiac tamponade. Emergent pericardiocentesis revealed purulent pericardial fluid with polymicrobial anaerobic bacteria, raising concern for gastrointestinal source and broad intravenous antibiotics were given. The pericardial fluid reaccumulated despite an indwelling pericardial drain and intrapericardial fibrinolytic therapy, necessitating a surgical pericardial window. Concurrent fluoroscopic oesophagram demonstrated oesophageal perforation with fistulous connection to the subcarinal mass and mediastinal drain, suggestive of oesophagopericardial fistula. Pathology from biopsy of the subcarinal mass returned with focal large necrotising granulomas consistent with histoplasmosis. Antifungal treatment was initiated, and the patient was eventually discharged home with nasogastric feeding tube and oral antibiotics and antifungals. This is the first reported case of polymicrobial pericarditis secondary to acquired oesophagopericardial fistula likely induced by mediastinal histoplasma lymphadenitis.