2001 Associates' Presentations
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High Tech Complications and the Case of the Dyspneic Retiree
James H. Mitchell M.D.
Michael C. Fraizer M.D.
Craig T. January M.D., Ph.D.
University of Wisconsin - Madison, Madison, Wisconsin
Purulent pericarditis is a rare medical condition that may be deadly, despite accurate diagnosis and treatment. The following is a case report of purulent pericarditis induced by transbronchial gene therapy injection for lung cancer.
The patient, a 65 year old male, had undergone gene therapy four weeks prior to presentation with an initially indolent course. Two weeks before admission, he developed worsening dyspnea, increasing abdominal girth, and low grade fevers. On presentation, he was found to be hypoxic, with an oxygen saturation of 77% on room air. His exam findings included elevated jugular venous pressure, decreased irregularly irregular heart sounds, and an estimated pulsus paradoxus of 15-20mm Hg. An echocardiogram showed a large pericardial effusion with early tamponade physiology, and fluoroscopic-guided pericardiocentesis was performed. Gram stain of the pericardial fluid revealed gram positive cocci in clusters, and subsequent cultures grew methicillin sensitive staph aureus.
The five currently accepted theories on the pathogenesis of purulent pericarditis include: direct spread from a pleural/mediastinal/ pulmonary focus, extension from a myocardial focus, seeding from a hematogenous infection, extension from a subdiaphragmatic suppurative focus, and direct inoculation as a result of iatrogenic interventions or trauma.
There has been only one previously documented case of transbronchial needle(TBN)-induced purulent pericarditis. Standard TBN biopsies involve the aspiration of pathologic material into the needle, thus preventing inoculation of the mediastinum with normal skin/oral flora acquired on passage of the bronchoscope. In this patient, it was hypothesized that injection of the gene therapy vector provided the medium for passage of the pathologic microorganisms, either directly into the pericardium, or by seeding of the bronchus with direct extension. This is the first reported case of purulent pericarditis as a complication of TBN gene therapy for lung cancer.
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