A 61-year-old immune-competent male with history of coronary artery disease preserved ejection fraction, and osteoarthritis of the knee was admitted with a 5-month history of increasing dyspnea, cough, lower extremity edema, and persistent atrial fibrillation. He was diagnosed with bilateral pleural effusions and loculated pericardial effusions (Figures 1(a) and 1(b)).
Pericardiocentesis and bilateral thoracentesis were performed: pericardial and pleural fluid revealed lymphocytic predominance (white blood cell count was 302 with 245 lymphocytes). Pleural fluid was transudate (pH was 7.5, LDH ratio was 0.35, and protein ratio was 0.3). Blood cultures were negative for P. acnes and peripheral blood smear showed rare atypical lymphocytes. Hence, the patient underwent a whole body 18FDG-PET scan to rule out malignancy. Quantiferon Gold (to rule out tuberculosis) and rheumatologic workup were negative. P. acnes was considered contaminant, but since it was isolated from both pleural and pericardial fluids, he was started on oral amoxicillin 1000 mg three times daily, with plans for a 21-day course.
The patient was readmitted 2 weeks later with recurrent pericardial and pleural effusions and New York Heart Association (NYHA) class III symptoms. On exam, he did not have evidence of pulsus paradoxus. Jugular venous pressure was 7 cm and systolic blood pressure was in the 110-130 range. He underwent repeat pericardiocentesis and thoracentesis for relief of symptoms. Cultures of pericardial and pleural fluid were negative for P. acnes on oral amoxicillin therapy. Echocardiography after pericardiocentesis revealed evidence of constrictive physiology (Figure 1(c)) and MRI demonstrated pericardial thickening with delayed enhancement (following administration of gadolinium), suggesting the presence of active inflammation and/or fibrosis (Figure 1(d)). Intravenous Penicillin G (3 million units every 4 hours) and colchicine 0.6 mg twice daily were initiated for treatment of presumed P. acnes pericardial/pleural effusions, with significant improvement in symptoms within a few days. He received a six-week course of intravenous Penicillin G and was subsequently switched to oral doxycycline 100 mg twice daily for 6 weeks. The patient's exercise capacity progressively improved to the point that he was able to participate in an international competitive sporting event several months following discharge. On follow-up, the patient had no recurrence of effusions (Figures 2(a) and 2(b)). Repeat echocardiography performed 10 weeks after initiation of intravenous antibiotics confirmed resolution of constrictive physiology (Figure 2(c)).