Abstract 1123: The Fastest Way to a Woman’s Heart Is through her Stomach: An Unusual Case of Fulminant Pericarditis
We present the case of a 50-year-old nurse, with past medical history of gastroesophageal reflux status post Nissen fundoplication 13 years prior, asthma, depression, and anxiety, who presented with a three-month history of pleuritic left-sided chest pain, shortness of breath, and fatigue. The patient was febrile at presentation; ECG showed sinus tachycardia and T-wave flattening, and chest x-ray showed an enlarged cardiac silhouette. Echocardiography revealed a moderate-sized pericardial effusion with echocardiographic evidence of tamponade physiology including respirophasic variation in mitral and tricuspid inflows. The patient underwent emergent pericardiocentesis followed by surgical pericardial window placement. Hemodynamics improved, but the patient’s respiratory status continued to decline, and intubation was performed. Empiric treatment was initiated with azithromycin, steroids, and aspirin. Days later, cultures from the pericardial drain sample, pericardial window sample, and pleural fluid grew Proprionibacterium acnes. The pericardial pathology returned, noting intense inflammation and a focal abscess collection surrounding a small piece of plant matter. Therefore, there was concern for communication between the gastrointestinal tract and pericardial space; upper endoscopy was performed. This demonstrated a 6 cm ulcer in the right lateral gastric wall, above the diaphragm due to the patient’s recurrent hiatal hernia, through which the lateral wall of the heart was plainly visible. The gastropericardial fistula was surgically repaired. Unfortunately, the patient continued to decline from a respiratory standpoint, with ventilator-associated pneumonia and progressive hemodynamic instability, and passed away on hospital day 36. In conclusion, we present the case of a patient with a gastopericardial fistula, a rare complication of esophageal or upper gastric surgery. Although exceedingly rare, gastropericardial fistula should be included on the differential for patients with unexplained pericarditis and a history of such surgery. This case illustrates the importance of considering a broad differential and employing multi-modality diagnostic tools when caring for patients with pericardial disease.