Abstract 4365017: A Rare Case of Purulent Methicillin-Resistant Staphylococcus Aureus Pericarditis Presenting with Septic Shock

Description of Case: A 66-year-old man with polysubstance use and chronic kidney disease presented with dyspnea, chest pain, urinary retention, and abscesses one week after high-risk sexual activity and ongoing methamphetamine use. Labs demonstrated leukocytosis (40.95 x 10^3/uL), elevated creatinine (3.2 mg/dL), HS-troponin (22 ng/L), and prostate-specific antigen (PSA) (229 ng/mL). Periareolar eschar and an indurated knee lesion were noted (Figure 1). His ECG showed diffuse ST-segment elevations and PR depressions (Figure 2). Transthoracic echocardiogram revealed normal biventricular function and a moderate pericardial effusion without tamponade physiology (Figure 3A). Left heart catheterization revealed non-obstructive coronary artery disease. He was found to be in septic shock requiring significant fluid resuscitation and vasopressor support. Continuing antibiotics, he underwent incision and drainage of both abscesses. Blood, wound, and urine cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Antibiotics were narrowed, and colchicine and aspirin were started for pericarditis after renal function improved. Transesophageal echocardiogram ruled out endocarditis. Persistent positive blood cultures, tachycardia, and leukocytosis prompted imaging to investigate other sources of infection, including the prostate, indicated by elevated PSA and recent ano-rectal intercourse. A CT scan revealed a large pericardial effusion and prostatic abscesses. While tamponade physiology remained absent, pericardiocentesis and drainage of prostatic abscesses were performed for source control. They yielded large volume purulent fluid drainage (Figure 3B), positive for MRSA, and sterile prostate drainage, respectively. After the pericardial drain output decreased, it was removed, and he continued an extended course of antibiotics, resulting in rapid improvement. Discussion: We report a case of a patient with purulent MRSA pericarditis. Although exceedingly rare, it poses a significant risk of morbidity and mortality, mainly due to cardiac tamponade potential. Recent literature includes sporadic cases, indicating a mortality rate of about 60% and tamponade progression in 42-77% of cases. The use of antibiotics has greatly reduced incidence of purulent pericarditis. Historically, this condition can spread contiguously or hematogenously, both of which are possible here. Prompt recognition and drainage is essential for timely treatment and effective source control.