We report the first case of purulent pericarditis with greenish pericardial effusion caused by Shewanella algae in a patient with gastric and gallbladder cancer. This case expands the reported spectrum of infection caused by S. algae and raises the possibility that S. algae is a causative pathogen for purulent pericarditis.
CASE REPORTA 76-year-old woman presented with fever and abdominal discomfort for 7 days. She had a history of gastric cancer, for which she had undergone radical gastrectomy, and gallbladder cancer, for which she had undergone cholecystectomy, and had resided in a nursing home for 8 months. On admission, the patient was afebrile and showed stable vital signs: temperature, 36.4°C; pulse rate, 94/min; respiratory rate, 18/min; blood pressure, 122/76 mm Hg. Abdominal examination found no evidence of hepatosplenomegaly or ascites. The jugular vein was not engorged, and there was no peripheral pitting edema. A chronic ulcerative lesion was noted on the lateral aspect of her left ankle. The white blood count was 18,800/mm 3 with neutrophil predominance (93%), hemoglobin was 9.9 g/dl, and the platelet count was 273,000/mm 3 . C-reactive protein was elevated, at 135 mg/dl (reference range, Ͻ6 mg/dl). Chest X-ray on admission showed no abnormalities (Fig. 1, left). Empirical antibiotic treatment with flomoxef (1 g every 8 h [q8h]) was prescribed for possible intra-abdominal infection after two sets of blood culture were done. On the eighth hospitalization day, the patient developed dyspnea and hypotension. Tachycardia with cardiac friction rub was noted on auscultation. A follow-up chest X-ray showed marked cardiomegaly with a flask shape (Fig. 1, right). Echocardiography revealed no evidence of infective endocarditis but a massive pericardial effusion with collapsed right ventricle. Emergent pericardiocentesis was performed, and 800 ml greenish pericardial fluid (Fig. 2) was drained out.Two sets of blood culture (Bactec 9240; Becton Dickinson, Sparks, MD) yielded a gram-negative bacillus. The aspirated pericardial fluid was inoculated onto the blood agar plate, eosin methylene blue agar, and chocolate agar (BBL Microbiology Systems, Cockeysville, MD) and subsequently yielded the same organism on these media. The isolate was initially susceptible to tigecycline, cefpirome, ceftazidime, amikacin, trimethoprim-sulfamethoxazole, imipenem, and piperacillintazobactam but resistant to ciprofloxacin (as determined by the disk diffusion test). Piperacillin-tazobactam (4.5 g q6h) was given for 10 days, and subsequent pericardial culture showed resistance to piperacillin-tazobactam. The antibiotic was then changed to imipenem (500 mg q6h). The patient was discharged to a general ward on the 16th day of intensive care unit stay and remained well at follow-up 2 weeks later.
