|Year : 2021 | Volume
| Issue : 3 | Page : 166-169
Right ventricular cardiac abscess secondary to traumatic osteomyelitis: Hematogenous dissemination from metaphysis to myocardium
Maitri Choudhary1, Munesh Tomar2
1 Department of Pediatric Cardiology, Manipal Hospital, Bengaluru, Karnataka, India
2 Department of Paediatric, LLRM Medical College, Meerut, Uttar Pradesh, India
|Date of Submission||29-Apr-2021|
|Date of Decision||13-Jun-2021|
|Date of Acceptance||09-Aug-2021|
|Date of Web Publication||31-Aug-2021|
Dr. Munesh Tomar
Department of Pediatric Cardiology, LLRM Medical College, Garh Road, Jai Bhim Nagar, Meerut - 250 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: A cardiac abscess is a suppurative infection involving cardiac tissues as myocardium, endocardium, and valves (native or prosthetic). The abscess could form as a direct extension of a preexisting cardiac focus such as bacterial endocarditis or from a distant septic focus leading to bacteremia. Clinical Description: We report an immunocompetent 3-year-old-child with a structurally normal heart presenting in septic shock secondary to right ventricle (RV) myocardial abscess. The abscess developed following hematogenous spread from neglected posttraumatic osteomyelitis of the left ankle and the causative organism was identified as methicillin sensitive Staphylococcus aureus. Management: Prompt action by a multidisciplinary team helped in reaching the diagnosis, effective management of septic shock, emergency open heart surgical removal of the septic mass, and concomitant lower limb arthrotomy saved the child from a bad outcome. Conclusion: This case reiterates the need for aggressive treatment of the open skeletal wound to prevent bacteremia and complications such as myocardial abscess. In a child presenting in septic shock, a quick point-of-care echocardiography is critical in ruling out possible underlying cardiac conditions such as bacterial endocarditis, myocardial abscess, or pericardial effusion. A high index of clinical suspicion is required to make a prompt diagnosis and aggressive medical and surgical intervention for good outcomes.
Keywords: Myocardial abscess, point-of-care echocardiography, posttraumatic osteomyelitis, septic shock
|How to cite this article:|
Choudhary M, Tomar M. Right ventricular cardiac abscess secondary to traumatic osteomyelitis: Hematogenous dissemination from metaphysis to myocardium. Indian Pediatr Case Rep 2021;1:166-9
|How to cite this URL:|
Choudhary M, Tomar M. Right ventricular cardiac abscess secondary to traumatic osteomyelitis: Hematogenous dissemination from metaphysis to myocardium. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:166-9. Available from: http://www.ipcares.org/text.asp?2021/1/3/166/325078
A cardiac abscess is a rare and fatal suppurative infection involving cardiac tissues as myocardium, endocardium, native or prosthetic valve and develops as a sequela of infective endocarditis in repaired or unrepaired congenital and/or acquired heart disease. It was first reported by Cossio et al. in an adult in 1933, as a delayed complication of bronchopneumonia. The abscess formation could be a direct extension of preexisting cardiac focus such as bacterial endocarditis or arise from distant septic foci secondary to seeding during bacteremia.,, In these cases, myocardial abscesses are usually multiple and small in size and can also involve other organs such as the kidneys, lungs, and brain. Other predisposing factors leading to myocardial abscesses include penetrating chest trauma, cardiac interventions, or acute myocardial infarction which are infrequently seen in children. Less commonly, it is secondary to bacteremia from a distant septic focus.
We present the case of a 3-year-old child with right ventricular myocardial abscess secondary to traumatic osteomyelitis, whose successful outcome can be attributed to the smooth collaboration between members of a multidisciplinary team (pediatrician, radiologist, cardiologist, and cardiothoracic vascular surgeon).
| Clinical Description|| |
A 3-year-old girl sustained trauma to her left ankle. This was treated conservatively with wound cleansing, analgesics, and local application of antibiotics. Within 10 days, a festering open wound developed at the same site with purulent bloody discharge [Figure 1] and she was prescribed oral antibiotics (amoxycillin-clauvulanate) and called after 1 week for review. The child was not brought back for 3 weeks. At presentation in the emergency, her parents gave a history of high-grade fever and severe respiratory distress for 3 days and decreased urine output for 2 days. On examination, the child was febrile (103°F), had tachycardia (heart rate 150/min), tachypnea (respiratory rate 50/min) had chest indrawing, feeble peripheral pulses, prolonged capillary filling time (>3 s), and blood pressure of 60/27 mm Hg (below 10th centiles). Her oxygen saturation was 92% in room air.
|Figure 1: Lateral aspect of left lower limb showing ulcerating wound located at the lower end with swelling of the foot|
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The child had an infected open wound on the left ankle that was discharging pus [Figure 1]. Salient systemic examination findings included cardiomegaly and a gallop rhythm; lethargy (Modified Glasgow Coma Scale 11), with normal sized and normal reacting pupils and absence of focal neurological signs, and soft tender hepatomegaly (3 cm beneath right subcostal margin in the mid-clavicular line). The arterial blood gas showed metabolic acidosis with respiratory (pH 7.2, pO2 60 mm Hg, pCO2 28 mmHg, base deficit minus 5, and elevated lactate of 5 mmol/L). The child had hyperglycemia (blood sugar 160 mg/dl) and normal serum electrolytes. A diagnosis of septic shock with right-sided congestive heart failure was made, and a possibility of traumatic osteomyelitis was kept.
| Management and Outcome|| |
Treatment was initiated as per the standard protocol for septic shock; intravenous fluid, noradrenaline infusion, oxygen, broad-spectrum intravenous antibiotics (Ceftriaxone and Amikacin). Preliminary laboratory investigations showed raised C-reactive protein (116 mg/L), leukocytosis (total leukocyte count 26,400/mm3 with neutrophilic predominance and toxic granules), and hemoglobin 10.3 g/dl with normal platelet counts (2.3 lakhs/mm3). The child had mildly deranged liver (SGOT 56 unit/l, SGPT 60 unit/l), and renal function tests (blood urea 62 mg/dl and serum creatinine 1.2 mg/dl). Blood and local wound cultures were sent before starting antibiotics. Chest X-ray showed moderate cardiomegaly with right atrial enlargement. Magnetic resonance imaging of the left leg showed osteolytic changes in left lower tibia [Figure 2]. Clinical and laboratory investigations were in concordance making a final diagnosis of septic shock, multiorgan dysfunction including cardiac involvement secondary to posttraumatic osteomyelitis of lower end of tibia of the left leg.
|Figure 2: Magnetic resonance imaging of left lower tibia showing osteolytic lesion (arrows)|
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Point-of-care echocardiography revealed the absence of septal defects, normal cardiac valves, mild pulmonary arterial hypertension with pulmonary artery systolic pressure of 35 mm Hg and small pericardial effusion (5 mm) without tamponade. The entire right ventricle (RV) cavity was occupied with thick, mobile, shaggy, heterogeneous, echo dense mass (4 cm × 8 cm) extending from the free wall of RV to its outflow tract [Figure 3] and Video 1][Additional file 1]. There was severe RV dysfunction (tricuspid annular plane systolic excursion 4 mm, fractional area change 20%) with mildly reduced left ventricular (LV) contractility (LV ejection fraction 50%). A provisional echocardiographic diagnosis of large vegetation attached to RV myocardium along with infiltration to RV wall suggestive of a RV abscess was made. Electrocardiogram (ECG) showed sinus tachycardia, right ventricular hypertrophy by voltage with no conduction abnormality. High-resolution computed tomography (HRCT) of the chest with angiogram confirmed the diagnosis of RV abscess. A final diagnosis of RV abscess secondary to posttraumatic osteomyelitis and septic shock was made. Antibiotics were upgraded to include vancomycin.
|Figure 3: Two-dimensional echocardiography from parasternal short axis view at the level of ventricles showing big vegetation (arrow) attached to RV myocardium|
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The child's condition deteriorated and had to be intubated. Emergency cardiac surgery was performed by a multi-disciplinary team within 12 h of admission in view of refractory septic shock secondary to a cardiac abscess with ventricular dysfunction. The RV abscess with a large vegetation attached to the RV myocardium was confirmed intraoperatively. A huge purulent cystic mass adherent to the RV free wall (40 mm × 30 mm) was found extending from the moderator band to infundibulum. No vegetation or clots had embolized to the pulmonary arteries. Simultaneous open heart surgical removal of the septic mass and arthrotomy of the left ankle joint was done. The cardiac abscess and marrow from medullary cavity of left tibia were sent for culture and histopathology. These grew methicillin sensitive Staphylococcus aureus.
The child was successfully extubated on the 2nd postoperative day and weaned off inotropes by the 6th day. There were no postoperative events and she was discharged after 3 weeks of intravenous vancomycin and ceftriaxone followed by oral antibiotics for another 6 weeks. The child has been under follow-up since the last 7 years. Serial postoperative echocardiograms showed complete resolution of abscess, no valvular damage, normal cardiac function, and normal ECG. There is slight asymmetry between left and right lower limb length, although she can perform all her routine activities effortlessly.
| Discussion|| |
A cardiac abscess is a suppurative infection involving cardiac tissues. A review of the literature by Shah et al. described 16 patients with perivalvular abscesses associated with bacterial endocarditis during a 20-year period. The patients' ages ranged from 8 to 21 years, and 40% were due to S. aureus. The incidence of this complication is rare in children in comparison to adults, in whom up to 30%–40% of patients with myocardial abscess have native valve bacterial endocarditis. Garg et al. demonstrated 7% of 192 patients with infective endocarditis had cardiac abscesses. Children with Staphylococcus bacteremia have a 12% incidence of infective endocarditis, out of whom 90% have an underlying congenital heart disease.,
In this case, a 3-year-old immunocompetent child with a structurally normal heart, presented in septic shock secondary to the development of a large RV myocardial abscess with RV dysfunction. The primary focus of infection was partially treated posttraumatic osteomyelitis of left ankle joint. Blood culture and culture from surgical debridement of local wound grew methicillin sensitive S. aureus. A multidisciplinary approach and use of point-of-care echocardiography in a child with septic shock led to the early diagnosis of the myocardial abscess. Standard indications for surgical intervention in cardiac abscesses include severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 5–7 days. In our case, the child with large RV abscess presented in septic shock and had rapid clinical deterioration despite attempted medical stabilization that was salvaged only by an emergency open heart surgery and left lower leg debridement.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]