Aspergillus pericarditis

Involvement of the pericardium in invasive aspergillosis is relatively uncommon, occurring in less than 5% of cases on postmortem series (Young 1970, Meyer 1973, Hori 2002). Pericarditis mainly occurs as a consequence of direct spread from adjacent infected lung (Le Moing 1998). It is often seen in association with myocardial involvement, and may sometimes result from the rupture of a myocardial abscess (Walsh 1982). Infection can also be introduced during cardiac surgery (Carrel 1991).

Pericardial involvement may occur with or without associated pericardial effusion (Meyer 1973). Clinical features of pericarditis are apparent in over half of patients (Le Moing 1998). Patients may present with chest pain, ECG abnormalities or features of cardiac tamponade due to pericardial effusion. Constrictive pericarditis has been reported (Denning 1989) but is rare. Aspergillus pericarditis may rarely present as pneumopericardium (Muller 1987, van Ede 1994, Merino 1995), following the development of a communication between the bronchus and the pericardial space. Pericardial effusion has also been reported as a side effect of the treatment of aspergillosis with itraconazole (Günther 1993).

Pericarditis or pericardial effusion can be detected by ECG and echocardiography, although in some cases these investigations may appear normal (Ross 1985). As most patients have concomitant invasive pulmonary aspergillosis the cause of pericarditis may be apparent clinically. However, most cases are diagnosed by culture from pericardial fluid or tissue, and is often visible on direct microscopy (Le Moing 1998). Aspergillus fumigatus is most frequently isolated, but cases due to Aspergillus flavus (Cooper 1981, Walsh 1982, Gökahmetoğlu 2000) and Aspergillus niger (Luce 1979, Owens 1990) have also been reported.

Aspergillus pericarditis has a high mortality. Death may be directly related to pericardial involvement through cardiac tamponade (Walsh 1982) or occur following arrhythmia (Ozsahin 2001) or infarction (Carrel 1991) due to myocardial spread. Myocardial infarction may also occur in aspergillosis due to mycotic emboli from the pulmonary vessels or endocardium occluding the coronary circulation (Ross 1985, Andersson 1986, Schwartz 1989, Itoh 2006).

Medical treatment follows that of other forms of invasive aspergillosis. Voriconazole has been shown to achieve adequate levels within a pericardial effusion (Poupelin 2006), although inter-individual variability was seen. Pericardial drainage or pericardectomy was also performed in many published cases to control cardiac tamponade or treat local spread of disease. However, only a few successful outcomes have been reported (Cooper 1981, Viviani 1987, Denning 1989, Le Moing 1998, Poupelin 2006).

The reference section lists case reports of invasive aspergillosis where pericardial involvement was apparent during life, as well as postmortem series of patients with aspergillosis.

Involvement of the pericardium in invasive aspergillosis is relatively uncommon, occurring in less than 5% of cases on postmortem series (Young 1970, Meyer 1973, Hori 2002). Pericarditis mainly occurs as a consequence of direct spread from adjacent infected lung (Le Moing 1998). It is often seen in association with myocardial involvement, and may sometimes result from the rupture of a myocardial abscess (Walsh 1982). Infection can also be introduced during cardiac surgery (Carrel 1991).

Pericardial involvement may occur with or without associated pericardial effusion (Meyer 1973). Clinical features of pericarditis are apparent in over half of patients (Le Moing 1998). Patients may present with chest pain, ECG abnormalities or features of cardiac tamponade due to pericardial effusion. Constrictive pericarditis has been reported (Denning 1989) but is rare. Aspergillus pericarditis may rarely present as pneumopericardium (Muller 1987, van Ede 1994, Merino 1995), following the development of a communication between the bronchus and the pericardial space. Pericardial effusion has also been reported as a side effect of the treatment of aspergillosis with itraconazole (Günther 1993).

Pericarditis or pericardial effusion can be detected by ECG and echocardiography, although in some cases these investigations may appear normal (Ross 1985). As most patients have concomitant invasive pulmonary aspergillosis the cause of pericarditis may be apparent clinically. However, most cases are diagnosed by culture from pericardial fluid or tissue, and is often visible on direct microscopy (Le Moing 1998). Aspergillus fumigatus is most frequently isolated, but cases due to Aspergillus flavus (Cooper 1981, Walsh 1982, Gökahmetoğlu 2000) and Aspergillus niger (Luce 1979, Owens 1990) have also been reported.

Aspergillus pericarditis has a high mortality. Death may be directly related to pericardial involvement through cardiac tamponade (Walsh 1982) or occur following arrhythmia (Ozsahin 2001) or infarction (Carrel 1991) due to myocardial spread. Myocardial infarction may also occur in aspergillosis due to mycotic emboli from the pulmonary vessels or endocardium occluding the coronary circulation (Ross 1985, Andersson 1986, Schwartz 1989, Itoh 2006).

Medical treatment follows that of other forms of invasive aspergillosis. Voriconazole has been shown to achieve adequate levels within a pericardial effusion (Poupelin 2006), although inter-individual variability was seen. Pericardial drainage or pericardectomy was also performed in many published cases to control cardiac tamponade or treat local spread of disease. However, only a few successful outcomes have been reported (Cooper 1981, Viviani 1987, Denning 1989, Le Moing 1998, Poupelin 2006).

The reference section lists case reports of invasive aspergillosis where pericardial involvement was apparent during life, as well as postmortem series of patients with aspergillosis.

Dr Adam Jeans

Department of Infectious Diseases and Tropical Medicine, Pennine Acute Hospitals NHS Trust, 
North Manchester General Hospital, 
Manchester, UK 
adam.jeans@doctors.org.uk

June 2009