Eur J Cardiothorac Surg 2002;21:591-592
© 2002 Elsevier Science NL
Pericardial constriction caused by Candida albicans
J. Benedík, Jr*,
J. 
ern
,
J. Benedík,
M. Dendis
Laboratory of Human Genetics, Centre for Cardiovascular Surgery and Transplantations, Pekarska 53, 656 91 Brno, Czech Republic
Received 25 September 2001;
received in revised form 2 November 2001;
accepted 5 November 2001.
* Corresponding author. Tel.: +42-05-4318-2548; fax: +42-05-4318-2547
e-mail: jasben{at}cktch.cz
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Abstract
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An uncommon occurrence of constrictive pericarditis caused by Candida albicans and its treatment by successful pericardectomy and epicardectomy are described. For pathogen detection, both cultivation and molecular diagnostics were used. The speed and reliability of molecular diagnostics using polymerase chain reaction make this method a powerful tool for pathogen detection in any clinical specimen.
Key Words: Pericarditis • Constriction • Candida albicans
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1. Introduction
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Constrictive pericarditis is a fibrous thickening of the pericardium, sometimes connected to the epicardium, resulting in chronic cardial compression. Its pathophysiology and clinical manifestations are well described, but its etiology varies [1]. In some cases, the cause of this condition remains unknown, even after microscopic and culture examination of scar tissue after surgery. A very useful diagnostic tool could be the polymerase chain reaction, which can quickly disclose viral, bacterial, or fungal pathogens in excised tissues, leading to immediate focused therapy [2]. In the past, tuberculosis has been one of the most frequent causes of constrictive pericarditis [3]. Other possible causes are bacterial, fungal, viral, or parasitic agents, neoplastic causes, connective tissue disease, trauma, renal failure, radiation, and foreign body in the pericardium. It can sometimes occur after cardiac surgery or after pacemaker or defibrillator implantation [4–9]. An extremely rare cause of constrictive pericarditis is Candida albicans. One such case of this type of constrictive pericarditis observed and recorded in our centre is the subject of this article.
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2. Case report
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A 70-year-old man with no history of tuberculosis, collagen diseases, or trauma, but suffering from type II diabetes mellitus and hypertension was referred to our centre. Physical examination showed signs of right-sided heart failure, with bilateral pleural effusions, liver enlargement, and small ascites. Biochemical examination results were quite normal, but X-ray examination showed a slightly enlarged cardiac shadow and bilateral pleural effusions. An electrocardiogram showed low voltage of the QRS complex. Echocardiographic examination confirmed thickening of the pericardium up to 10 mm, good function of the left ventricle, and constriction of the right ventricle with congestion of the venous system and liver. During the right-side catheterization, we found high pressure in the right atrium, -14 mmHg, and elevated end-diastolic pressure. Surgery was recommended after these findings.
2.1. Surgery
Median sternotomy was selected as the surgical procedure. After opening the thorax, thick and strong, but uncalcified, pericardium was found and excised by layers. The pericardial cavity was completely occluded, with tissues growing through the epicardium (Fig. 1)
. Pericardectomy and partial epicardectomy of the right atrium and ventricle were performed, significantly improving right ventricle motion and lowering right atrial pressure.
Both bacteriological and molecular genetic examination of the pericardium proved C. albicans infection. PCR detected a typical 326 bp (326 base pairs) length band on electrophoretic gel (Fig. 2) in less than 5 h after the operation. The same results, received by cultivation, were available several days later.
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Fig. 2. Molecular detection of C. albicans. Line 1: molecular weight marker. Line 2: positive control. Line 3: negative control. Line 4: patient positive for C. albicans. Internal control: 520 bp. Specific band for C. albicans: 326 bp.
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The post-operative period was longer than normal, due to prolonged inotropic support and rehabilitation. Blood loss was minimal; the patient was extubated on the first post-operative day. After pathogen specification, therapy with diflucan (200 mg/day) for 15 days was applied. On the 16th day, the patient was discharged in good condition. He remains in a good condition without any recurrence of constriction.
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3. Discussion
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Constrictive pericarditis has been known for centuries. In some cases, its nature remains unknown even after microscopic and culture examinations. Forty-two percent of these cases are presumed to be of viral or bacterial origin [1]. In the past, tuberculosis was the most frequent cause of constrictive pericarditis [1,3]. Other causes of constriction can be a neoplastic disease with infiltration of pericardium, or constriction after radiation therapy, especially if mediastinal tumours are involved [8,9]. The incidence of constrictive pericarditis after cardiac surgery and after penetrating chest trauma is about 0.3% [1,7]. Another cause can be a rheumatoid disease [4]. Fungal origin of constrictive pericarditis is extremely rare and detection of the pathogen is laborious and time-consuming with low efficacy, especially in some species (e.g. Aspergillus) [5,6]. In our previous publications, we have shown that a molecular diagnostic approach by the use of PCR assay and/or other methods of molecular diagnosis is efficient, reliable, and sufficiently robust for detection of almost all pathogens in any clinical specimen [10]. The speed and independence of pathogen detection on cultivation make this method useful in treating any cardiovascular disorder, where pathogen involvement is expected and where time plays an important role.
As described earlier, a case of constrictive pericarditis due to C. albicans was successfully treated. The C. albicans infection was detected by both PCR assay and cultivation. The recovery of the patient's heart function after surgery and targeted therapy was complete.
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Acknowledgments
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This work has been supported in part by a grant from the Internal Grants Agency of the Ministry of Health of the Czech Republic (grant NM6780-3/2001).
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Abstract
1. Introduction
