Quick Fire Cases
Arleen Ramirez Jimenez, MD
Cardiac Advanced Imaging Fellow
University of Florida
Arleen Ramirez Jimenez, MD
Cardiac Advanced Imaging Fellow
University of Florida
Anita Wokhlu, MD
Cardiologist
Malcolm Randall Veterans Medical Center
Christina Arraut Hernandez, MD
Cardiac Advanced Imaging Fellow
University of Florida
Bruno Hochegger, MD
Radiologist
University of Florida
A 55-year-old woman with diabetes mellitus and recurrent Methicillin Sensitive Staphylococcus aureus (MSSA) infections was transferred to our hospital with persistent MSSA bacteremia despite receiving antibiotic therapy with Cefazolin, and for evaluation of a left ventricular (LV) pseudoaneurysm identified on abdominal magnetic resonance image (MRI). A whole body Fludeoxyglucose F18-positron emission tomography (PET) study showed perinephric abscess, as well as a LV apical mass with significant uptake contiguous with the LV cavity concerning for a mycotic pseudoaneurysm versus cardiac or pericardial mass. Echocardiography with contrast revealed low normal LV systolic function, with apical dyskinesis but no LV pseudoaneurysm or pericardial abnormality was visualized.
Diagnostic Techniques and Their Most Important Findings:
A chest computed tomography (CT) with contrast demonstrated a rim of enhancing fluid collection overlying the LV apex suggestive of pericardial abscess. Given the multiple other modalities suggestive of LV pseudoaneurysm, cardiac MRI (cMRI) was performed to delineate the myocardium and pericardium. Cine imaging showed LV apical dyskinesis with underlying subendocardial late gadolinium enhancement (LGE) in the anterior, anterolateral, and apical walls due to a prior LAD infarct and intact myocardium without aneurysm or pseudoaneurysm. In addition, a complex, heterogeneous appearing, curvilinear pericardial effusion was identified adjacent to LV apex, contained within a rim of thickened pericardium. T1 parametric mapping of effusion demonstrated values suggestive of exudate, e.g., 1220ms. Finally, LGE demonstrated an enhancing, heterogeneous fluid collection with a distinct rim, adjacent to the LV apex. The CT and MRI findings in tandem supported pericardial abscess without myocardial involvement. Subsequently, cardiothoracic surgery performed a pericardial abscess incision and drainage which yielded a caseating purulent material with minimal fluid consistent with abscess. Cultures of the collected fluid did not grow any organism but were felt to be sterile due to ongoing antibiotic treatment.
Learning Points from this Case:
Pericardial abscesses are rare, but life-threatening complications of infection. cMRI plays a pivotal role in assessing pericardial pathologies ranging from simple effusions or cysts to inflammatory pericarditis or infectious abscesses requiring expeditious intervention. The value of cMRI, in this case, was better structural delineation of myocardial versus pericardial processes which enabled the surgical team to determine that a surgical intervention was preferred over centesis, and guided them to limit the intervention to the pericardium. In addition, cMRI, even when compared with CT, provides tissue characterization and identification of inflammation in this high-risk pericardial effusion where abscess is a concern.
