A fatal Candida albicans pericarditis presenting with cardiac tamponade after COVID‐19 infection and cardiothoracic surgery

Abstract Background Candida pericardial infection is a rare clinical entity usually related to recent cardiothoracic surgery and chronic debilitating conditions. During the COVID‐19 pandemic, invasive fungal infections have been on the rise, likely due to a combination of factors such as immunosuppression, underlying conditions like diabetes, and surgical procedures. Case Presentation Herein, we report a 67‐year‐old diabetic woman with a history of COVID‐19 infection who received a high dose of corticosteroids a few months before admission, and previous myocardial infarction for more than 12 years. The patient had a positive cardiac tamponade with signs of dyspnea, chest pain, and low blood pressure. Echocardiographic data were more in favor of constrictive pericarditis. The patient underwent urgent echocardiography‐guided pericardiocentesis and then broad‐spectrum antibiotic treatment was prescribed. Repeated echocardiography implied a persistent pericardial effusion 10 days later. Subxiphoid aspirates and biopsied tissues showed budding yeast cells and yeast colonies grew on culture media identified as Candida albicans. Conclusion This report should bring to the attention of physicians toward the possibility of Candida pericardial infection presenting with cardiac tamponade after COVID‐19 infection and cardiothoracic surgery. Echocardiographic assessment, prompt pericardiotomy, molecular‐based identification of causative agent, and early administration of appropriate antifungal treatment should improve the patient's survival.


| INTRODUC TI ON
Pericarditis is an inflammation of the pericardium which can be infectious and non-infectious.The most common causes of infectious pericarditis are virus, bacteria, and fungi. 1 Most of them are idiopathic and viral, a benign condition that resolves spontaneously.
Pericarditis is a known complication of a number of viral infections, including the flu virus, coxsackievirus, echovirus, and coronavirus. 2 a report, 4.6% of patients with COVID-19 infection had evidence of pericardial effusion. 3Purulent pericarditis while rare, is characterized by suppurative pericardial fluid, which usually comes from the expansion of a bacterial infection site near or through the diffusion of blood. 4Bacteria and fungi are relatively uncommon cause but more likely lead to purulent pericarditis with cardiac tamponade and pericardial constriction consequences. 4Non-infectious pericarditis following acute myocardial infarction has also been reported. 5This condition is often associated with fatal outcomes.
Fungal pericarditis is usually caused by Candida species, while Aspergillus species have also been reported 4 that can be fatal if not treated promptly and appropriately. 6,7Candida pericarditis is a rare condition described primarily in patients with recent cardiothoracic surgery, chronic debilitating illnesses, and immunosuppression resulting from malignancy, chronic therapy with corticosteroids and antibiotics or primarily by gastropericardial fistulas following gastric surgery, which is usually fatal and, unless treated, leads to impaired cardiac function. 8Candida pericarditis is caused by at least 15 potentially virulent Candida species.Aspergillus species have been also reported as causative agents in immunocompromised patients. 9Amphotericin B and surgical drainage have been reported successful. 7erall mortality due to this clinical entity is significantly high (75%) and is attributed mainly to difficulty in diagnosis due to subtle clinical clues and insidious onset. 10Here, we report a fatal case of purulent pericarditis caused by Candida albicans presenting with cardiac tamponade after COVID-19 infection and cardiothoracic surgery.The transthoracic echocardiography has demonstrated left ventricular (LV) hypertrophy with normal LV systolic function, abnormal interventricular septal motion, and septal shift (septal bounce), mild left atrial enlargement, significant respiratory variation mitral valve and tricuspid valve (more than 40%), thick aortic valve with mild aortic insufficiency, a thick pericardium with mild pericardial effusion with dilated inferior vena cava (IVC) without inspiratory collapse.
Echocardiographic data were more in favor of constrictive pericarditis consistent with cardiac tamponade physiology; the patient underwent urgent echocardiography-guided pericardiocentesis and empiric, broad-spectrum antibiotics including meropenem (1 g IV q8hr) and vancomycin (1 g IV q12hr) were prescribed.The laboratory tests showed that the patient had leukocytosis with a WBC count of 44,300/μL.Additionally, pericardial fluid analysis revealed an average of 14,600 leukocytes/μL, with a differential count predominantly consisting of neutrophils (95%) and lymphocytes (5%).
Chest x-ray showed cardiomegaly, and a mass of 5 cm under the previous surgical scar, which was moved by the pressure of the probe (Figure 1).Repeat echocardiography (on May 10, 2022)

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C A S E REP ORT On April 29, 2022, a 67-year-old diabetic woman with a past medical history of confirmed SARS-CoV-2 infection and receiving a high dose of corticosteroids about 6 months before admission, and previous myocardial infarction (about 12 years before hospitalization), was referred to the Mazandaran Heart Center affiliated with the Mazandaran University of Medical Sciences, northern Iran, complaining of chest pain, shortness of breath, excessive sweating, and pressure in the left thoracic region that had spread to the left hand, decreased in systolic blood pressure, and tachycardia.On May 1, 2022, the laboratory tests showed mild leukocytosis (WBC count: 11,300/μL: including neutrophils 85% and lymphocytes 13%) with elevated levels of inflammation biomarkers such as erythrocyte sedimentation rate (111 mm/h) and C-reactive protein (77 mg/L).
results were normal LV size and function (LVEF 50%), moderate LV hypertrophy (LVH), septal hypokinesia, normal right ventricle size and function, thick mitral valve with mitral regurgitation, mild tricuspid regurgitation, mild pericardial effusion, normal pulmonary arterial pressure, with normal sinus rhythm in ECG, which all data implied a persistent pericardial effusion.So, the previous subxiphoid incision was opened, a large amount of pus was removed from the right atrium, and the sample was sent to a laboratory for diagnosis.The microbiological culture of the pericardial fluid yielded Candida albicans and antifungal treatment with intravenous voriconazole (loading dose, 400 mg q12 h and maintenance dose, 200 mg q12 h) was started.The direct microscopy examination of biopsied tissues and the secretions showed budding yeast cells (Figure 2), and culture on sabouraud dextrose agar after 1-day incubation at 37°C yielded moist yeast colonies.Based on microscopic and macroscopic characteristics, it was identified as a Candida species and confirmed by polymerase chain reaction (PCR) of the ITS gene and sequencing.The amplicons were sequenced and compared with the GenBank database (https:// blast.ncbi.nlm.nih.gov/Blast.cgi) for accurate identification.Based F I G U R E 1 Chest x-ray showing cardiomegaly.