Horse bacterium causes human pericardial and pleural effusion

In March 2009, a 51-year-old man presented at the emergency department (University Medical Centre Mannheim, Germany) on a Thursday afternoon with intermittent fever (up to 40 C), tinnitus, chronic fatigue, paleness, paroxysmal angina pectoris, and progressing shortness of breath for the last 2 weeks. The patient had a history of aggressive centroblastic non-Hodgkin lymphoma (i.e., B-cell lymphoma, primary location at the thorax and pleura, Ann Arbor stage IVA, first diagnosed in June 1995), having been treated by six cycles of CHOP (cyclophosphamide, hydroxydaunorubicin, oncovin/vincristine, prednisolone)-adapted chemotherapy and adjuvant radiation without any residuals to date. Neither any specific co-morbidity nor any crucial cardiovascular risk factors were identifiable. In his professional life, the patient is a hard-working groom at his horse ranch and passionately rides horseback in his free time. Physical examination revealed low heart murmurs without any additional heart sound, fast but weak peripheral pulses (heart rate 160 bpm), arterial hypotension of 80/ 60 mmHg, and a pulsus paradoxus of 15 mmHg. Auscultation of the lung revealed loss of breath sounds and muffled percussion was detectable of about 3 cm upward from the lungs’ base. No peripheral edema were present. Electrocardiography (ECG) showed atrial fibrillation with rapid ventricular response and low central voltage (defined as lower than 0.5 mV in extremity leads, and lower than 0.7 mV in precordial leads) (Fig. 1). Computed tomography of the thorax showed significant pericardial effusion of 4 cm in diameter around the heart, significant pleural effusions on both lungs (up to 3.5 cm), and reactive mediastinal and axillary lymphadenopathy (Fig. 2). Immediate echocardiography confirmed massive pericardial effusion around the heart with slightly reduced left ventricular function and an irregular pendular movement of the heart within the pericardial space (like a ‘swinging heart’). Complete blood count indicated an inflammatory response [C-reactive protein 101 mg/l (normal range 0–5 mg/dl), neutrophile granulocytes 7.2 9 10/l (88%) (normal range 2.2–6.3 9 10/l), platelets 446 9 10/l (normal range 145–348 9 10/l)] and increased cardiac load, as indicated by increased NT-proBNP value (935 pg/ml, normal range 0–300 pg/ml). Consequently, this patient was diagnosed to suffer from acute pericardial and pleural effusion due to systemic infection of—at that point in time—unknown origin. Lactate dehydrogenase (LDH) level was in the normal range, as well as serum creatinine as an indicator of renal function (1.1 mg/dl, normal range 0.7–1.3 mg/dl). Hematologic analyses revealed normocytic anemia (hemoglobin 12.1 g/dl, normal range 13.2–16.7 g/dl) and moderate/ severe lymphopenia (5.6%; normal range 13–53%). These abnormalities were interpreted to be lymphoma and chemotherapy related. In the intensive care unit, 1,000 ml of turbid yellow pericardial effusion was drained through a subxiphoid pigtail catheter. Thereafter, cardiac contractility improved significantly, as assessed by echocardiography (Simpson’s biplane ejection fraction 54%). The pericardial fluid contained 0.69 9 109 leucocytes/l, consisting of 66% M. Behnes (&) K. Mashayekhi M. Borggrefe First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1–3, Mannheim 68167, Germany e-mail: Michael.Behnes@umm.de