International Journal of Cardiology 176 (2014) 1345–1347

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Letter to the Editor

Melioidosis: A rare cause of constrictive pericarditis Chun Pong Wong ⁎, Wenjie Huang, Quek Wei Yong, Hee Hwa Ho Department of Cardiology, Tan Tock Seng Hospital, Singapore

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Article history: Received 28 May 2014 Received in revised form 26 July 2014 Accepted 28 July 2014 Available online 6 August 2014 Keywords: Melioidosis Burkholderia pseudomallei Constrictive pericarditis

We report a case of melioidosis complicated by constrictive pericarditis. A 38-year-old Malay gentleman presented with progressive exertional dyspnea for 1 month, associated with bilateral ankle edema and ascites. He worked as an engineer at a shipyard in Singapore. He had a history of melioidosis with a positive culture of Burkholderia pseudomallei from pericardial fluid last year, which was managed with pericardiocentesis and antibiotics for six months. During this admission, chest X-ray revealed bilateral pleural effusion. Pleural fluid analysis was shown to be transudative. Electrocardiogram at rest showed sinus rhythm with small QRS complexes. Renal function test was normal but liver panel showed congestive picture. Ultrasonography of the abdomen showed ascites but no evidence of cirrhosis or biliary obstruction. Computed tomography of the chest showed significant pericardial thickening and bilateral pleural effusion (Fig. 1a). Echocardiogram showed a preserved left ventricular systolic function with ejection fraction ~ 50%, bi-atrial enlargement (Fig. 1b), septal bouncing, and inferior vena cava & hepatic vein dilation with restricted respiratory variation (Fig. 1c). Doppler study showed an increased early diastolic filling velocity i.e. high E wave, with an E/A ratio of 2 and short E-wave deceleration time of 97 ms in the mitral inflow (Fig. 1d), ~20% decrease in the left ventricular outflow tract flow velocity with inspiration (Fig. 1e), and tissue Doppler imaging showed an increased mitral annular e′ velocity of ~14 m/s (Fig. 1f). These were all suggestive of constrictive pericarditis. However, the mitral inflow E-wave velocity was only decreased by ~18% with inspiration (Fig. 1g), and tricuspid inflow E-wave velocity ⁎ Corresponding author at: Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. E-mail address: [email protected] (C.P. Wong).

http://dx.doi.org/10.1016/j.ijcard.2014.07.269 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.

was increased only ~18% with inspiration (Fig. 1h). There was a slight increase in systolic and diastolic velocities with inspiration, but no increased flow reversal. In view of the discrepancy among the findings in echocardiogram, cardiac catheterization was arranged. Coronary angiography revealed minor coronary artery disease. The left and right cardiac catheterizations were found raised and end diastolic pressures in all chambers, which were about 22–24 mm Hg, were equalized. Right atrial tracing showed an M pattern with rapid x, y descent and v wave is greater than a wave (Fig. 2a). Simultaneous recording of the left and right ventricular pressure tracings showed the dip and plateau configuration, also called the square root sign and feature of ventricular interdependence i.e. discordance of the left and right ventricular pressures with respiratory variation (Fig. 2b), which were specific and diagnostic for constrictive pericarditis. Melioidosis, also called Whitmore's disease, is an infectious disease caused by a Gram negative bacterium, B. pseudomallei, which is found in soil and water. It is endemic in South-east Asia and Northern Australia. It is spread through a direct contact with the contaminated source. The term, melioidosis, is a Greek word meaning “a condition similar to the distemper of asses”. The symptoms of melioidosis depend on the site of the infection and this can vary. Pulmonary involvement is the commonest presentation but localized symptoms such as skin ulcers, boils, joint or bone infections and even pericarditis do occur. The diagnosis of melioidosis is made by growing the bacteria with laboratory testing of blood, sputum, urine or a swab from an abscess or non-healing ulcer. It should be treated with antibiotics, which usually have to be continued for at least three months. If treatment is started early, recovery is usually complete. It is important to complete all antibiotics to prevent a relapse [1]. A PubMed search of the terms melioidosis, pericardial, pericarditis and constrictive pericarditis till May 2014 was conducted. There is no case report of constrictive pericarditis complicating melioidosis so far. On the contrary, there are a lot of case reports of melioidosis complicated by pericarditis or pericardial effusion [2–6]. However, Chetchotisakd et al. reported that 83% of the patients diagnosed melioidosis (10 out of 12) in his registry developed constrictive pericarditis [5]. Therefore, even after the full course antibiotic treatment of the acute stage of melioidosis, we should still follow up the patients and screen for late complications especially the development of constrictive pericarditis after pericarditis or pericardial effusion. Since global travel becomes more and more common and convenient nowadays, even though melioidosis is endemic in South-east Asia and Northern Australia, infected travelers may travel and present to any institution all over the world. Therefore, it is essential for clinicians around the world to know about the presentation, management and possible complications of melioidosis.

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C.P. Wong et al. / International Journal of Cardiology 176 (2014) 1345–1347

Fig. 1. a. CT image showing thickening of the pericardium. b. Echocardiographic apical 4 chamber view showing the dilated left and right atria. c. M mode Doppler study of the inferior vena cava. d. Pulsed wave Doppler study of the mitral inflow. e. Pulsed wave Doppler study of the left ventricular outflow tract. f. Tissue Doppler imaging showing an increased mitral annular e′ velocity. g. Pulsed wave Doppler study of the mitral inflow showing variation with respiration. h. Pulsed wave Doppler study of the tricuspid inflow showing variation with respiration.

Fig. 2. a. Right atrial tracing showing an M pattern with rapid x, y descent and v N a wave. b. Simultaneous recording of the left and right ventricular pressures showing the dip and plateau configuration, also called the square root sign.

For our young gentleman, he was referred to a cardio-thoracic surgeon for pericardiectomy in view of the constrictive pathology causing cardiac failure.

Conflict of interest The authors report no relationships that could be construed as a conflict of interest.

Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Centers for Disease Control and Prevention website. http://www.cdc.gov/melioidosis/; May 27 2014.

C.P. Wong et al. / International Journal of Cardiology 176 (2014) 1345–1347 [2] Ruff MJ, Lamkin Jr N, Braun J, et al. Melioidosis complicated by pericarditis. Chest Feb. 1976;69(2):227–9. [3] Lim KB, Oh HM. Melioidosis complicated by pericarditis. Scand J Infect Dis 2007; 39(4):357–9. [4] Chung HC, Lee CT, Lai CH, et al. Non-septicemic melioidosis presenting as cardiac tamponade. Am J Trop Med Hyg Sep. 2008;79(3):455–7.

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[5] Chetchotisakd P, Anunnatsiri S, Kiatchoosakun S, et al. Melioidosis pericarditis mimicking tuberculous pericarditis. Clin Infect Dis Sep. 1 2010;51(5):e46–9. [6] Schultze D, Müller B, Bruderer T, et al. A traveller presenting with severe melioidosis complicated by a pericardial effusion: a case report. BMC Infect Dis Oct. 4 2012;12:242.

Melioidosis: a rare cause of constrictive pericarditis.

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