Male patient, 34 years old, with a history of acute myeloid leukemia M4 diagnosed 10 years ago, successfully treated with cytarabine and doxorubicin, and maintained in complete remission.
Six years later, advanced chronic kidney disease was detected and the patient was admitted to hemodialysis with a tunneled, double-lumen catheter.
The etiology of the nephropathy could not be specified and, having ruled out obstructive factors, it was attributed to sequelae of episodes of acute renal failure and toxicity by chemotherapy.
Several months prior to the consultation he had undergone a procedure of extraction of upper molars in which he was premeditated with 1 g of oral amoxicillin once and had been immitted in intensive care unit for pneumonia.
This last episode was complicated by septic shock, which required invasive mechanical ventilation and vasoactive amines, and was discharged in good clinical condition one week later.
Three months later he began to experience poor tolerance to hemodialysis sessions due to hypotension, and he also showed hepatomegaly and ascites.
The following month, the patient was admitted to the emergency department due to marked edema, accompanied in the last hours by dyspnea.
Initially it was attributed to an acute pulmonary edema, starting emergency hemodialysis and low flow therapy, achieving a partial response of its symptoms.
In her laboratory study she was taken radiography on one day without dialysis) showed moderate normocytic-normochromic anemia, with hemoglobin of 7.4 g/dl, creatininemia of 5.8 mg/dl and pleural effusion of 7.3 hemidia.
A transthoracic echocardiography was performed which concluded an abundant pericardial effusion, predominantly posterior, with no signs of tamponade but clear fibrinoid type adhesions between the visceral and parietal pericardium, with no images suggestive of endocarditis.
Percutaneous pericardial drainage was performed, which resulted in initial removal of 120 ml of helixate NexGen during the days following 400 ml.
Blood cultures and cultures of pericardial fluid were negative.
The post-puncture echocardiographic control showed a decrease in the amount of the effusion; however, a moderate amount of pericardial fluid persisted in the area of the lateral and posterior wall of the left ventricle, where thick adhesions were observed.
Right ventricular filling also showed clear constrictive characteristics.
The directed study showed no vegetations or indirect signs of endocarditis.
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Consequently, surgical treatment was performed by pericardial drainage and wide pericardiectomy.
Three samples corresponding to peripherical fluid, pericardium tissue and pericardium tissue were extracted according to local microbiological protocol. The pericardium fluid was inoculated into the pericardial effusion BD-3 ml/cultec (e.g.
After 48 hours of isolation, the patient showed bacterial growth.
Then, we proceeded to subcultivate soya-trypsin agar plates with 5% lamb blood, Polyvitex chocolate and Mac Conkey, incubating for 48, 72 h with a box in 37° C.
Direct Gram stain of the primary sample showed no bacteria, so the result of the subcultives was expected.
At 72 h, it was observed in soy-trypsin agar with 5% lamb blood and chocolate Polivitex, which in the long colony, the ple stain showed Gram negative direct development.
Pericardial tissue plaques also showed microbial development at 72 h.
We proceeded to identification with basic tests for sorbitol fast sugar obtaining negative catalase, positive oxylase, negative nitrates, in addition to additional tests such as indole positive, negative mobility, ornithine and hydrolysis of glucose.
It was determined that the isolated bacterium was a fastidious bacillus belonging to the HACEK group and biochemical tests identified it as C. hominis.
No antibiogram could be performed under local technical conditions or sent to reference laboratories.
The histological study of the pericardial tissue obtained during surgery showed fibrinous pericarditis.
The suspicion of a tuberculous etiology was initially ruled out due to the negativity of Ziehl-Neelsen stains and auramine in the peripherical biopsy and subsequent negative bacteriological cultures.
Pericardial tissue stains with SBP and creatinine levels were also negative for irbesartan.
Treatment with intravenous ceftriaxone, 2 g daily for 21 days was indicated to then remove the tunneled catheter and make a native arteriovenous fistula for hemodialysis.
An disappearance of hypotension episodes during dialysis and a clear decrease in ascites until resolved rapidly.
To date, three years after surgery, the patient has not presented febrile episodes or other significant intercurrent morbidities.
An ultrasound performed three months after surgery revealed only mild contractile dysfunction of the right ventricle and its last control two years later was completely normal.
From the dental point of view has maintained periodic controls without morbidity, their tolerance to hemodialysis is currently optimal and is completely reintegrated to their work activities.
