Case Reports in Hematology

Volume 2013 (2013), Article ID 452730, 3 pages

http://dx.doi.org/10.1155/2013/452730

Case Report

Morganella morganii Pericarditis in a Patient with Multiple Myeloma

Takafumi Nakao, Masahiro Yoshida, Hiroshi Kanashima, and Takahisa Yamane

Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan

Received 1 July 2013; Accepted 12 August 2013

Academic Editors: E. Arellano-Rodrigo, N. Hamerschlak, K. Konstantopoulos, and R. Lowenthal

Copyright © 2013 Takafumi Nakao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Purulent pericarditis caused by Morganella morganii is extremely rare. We report herein a case of a 61-year-old man who presented with chest pain and dyspnea fourteen days after chemotherapy for multiple myeloma. Echocardiogram and computed tomography revealed a massive pericardial effusion and associated cardiac tamponade. Pericardiocentesis was performed. Pericardial fluid was found to be purulent, and Morganella morganii was isolated from the fluid. The patient was successfully treated with antibiotic therapy and surgical drainage of the fluid. Morganella morganii should be considered a possible pathogen when immunocompromised patients develop purulent pericarditis.

1. Introduction

Morganella morganii is a gram-negative facultative anaerobe that is ubiquitous in the environment. The organism may cause many kinds of opportunistic infection; however, it is very rare for it to be a cause of purulent pericarditis. To date, only four articles in English [1–4] and one in Russian [5] have been published on purulent pericarditis caused by Morganella morganii.

Multiple myeloma is a neoplastic plasma cell dyscrasia characterized by a serum monoclonal protein, anemia, skeletal destruction, renal insufficiency, and hypercalcemia. Patients with multiple myeloma are at high risk of bacterial infections. Here, we describe a rare case of purulent pericarditis caused by Morganella morganii in a patient with multiple myeloma. Pericarditis was successfully managed with antibiotic therapy and pericardial drainage.

2. Case Report

A 61-year-old male was diagnosed with multiple myeloma (immunoglobulin IgG-κ type) in 2006. He underwent 2 cycles of combination chemotherapy consisting of vincristine, doxorubicin, and dexamethasone (VAD) that were very effective. Subsequently, he underwent high-dose chemotherapy (melphalan: 200 mg/m²) followed by tandem autologous peripheral blood stem cell transplantation. Although he achieved complete remission, multiple new lytic bone lesions were found in 2010. Salvage treatments were initiated, including MP therapy (melphalan and predonisolone) or bortezomib which were associated with a temporary response. In February 2011, lenalidomide was started in combination with dexamethasone. After 2 cycles of treatment, the patient developed massive pulmonary embolism. He underwent inferior vena cava filter placement, and thrombus suction was performed. In August 2011, he received repeat VAD therapy. Fourteen days after chemotherapy, when he was neutropenic, he had frequent bouts of diarrhea, high-grade fever, and dyspnea. One set of peripheral blood culture yielded a gram-negative rod within 24 h of incubation. The isolate was subsequently identified as Morganella morganii. Echocardiogram and computerized tomography (CT) revealed a massive pericardial effusion (Figure 1) and associated cardiac tamponade. Pericardiocentesis and pericardial fluid drainage was performed, and 1,200 mL of heavily blood-stained fluid was drained. The results of the pericardial fluid analysis were as follows: red blood cell count, 1.6 million cells/mm³; white blood cell count, 185,600 cells/mm³ with neutrophilia of 95.5%; total protein, 7.1 g/dL; glucose < 5 mg/dL; lactate dehydrogenase, 4,390 U/L. Morganella morganii grew in cultures of the pericardial fluid, and no myeloma cells were detected in the fluid. The patient was started on intravenous cefozopran. The chest drain was removed after 5 days and pericarditis responded well to 5-week antibiotic therapy. After pericardial fluid drainage and antibiotic treatment, there was no additional pericardial fluid accumulation, and follow-up blood cultures were negative. The patient had an uneventful recovery and did not experience any recurrence of pericarditis 2 years after his illness.

(a)

(b)

Figure 1: Chest CT scan showing large pericardial effusion (a) and echocardiogram showing circumferential pericardial effusion (b).

3. Discussion

Morganella morganii is a gram-negative facultative anaerobe that is commonly found in the environment and in the intestinal tracts of humans as normal flora. Despite its widespread distribution, it is a relatively uncommon cause of clinical human infections [6]. Urinary tract infection is probably the most common infection caused by Morganella morganii in humans [7]. Morganella morganii has also been documented as causing skin and soft tissue infections [8], peritonitis [9], meningitis [10], and bacteremia/sepsis [11]. However, Morganella morganii pericarditis is extremely rare. Common bacterial pathogens associated with purulent pericarditis include Streptococcus pneumoniae most frequently, Staphylococcus aureus, and gram-negative organisms such as Proteus species, Escherichia coli, Pseudomonas species, and Klebsiella species. Only four articles have been published in English on purulent pericarditis caused by Morganella morganii [1–4]. In three of these four cases, the patients were immunocompromised due to underlying diseases. One was a patient with X-linked agammaglobulinemia [3]. The other two patients developed pericarditis after allogeneic bone marrow transplantation for hematological malignancies. In these two patients, splenectomies were performed before the onset of pericarditis [1, 2]. Our patient also had a number of features predisposing to infection including multiple myeloma, immunosuppressive therapy, and pulmonary embolism treated with inferior vena cava filter placement. Our experience suggests that Morganella morganii should be considered a possible pathogen when immunocompromised patients develop purulent pericarditis.

Pericardial involvement and cardiac tamponade are rare complications of multiple myeloma. Cardiac tamponade has been reported to be caused by amyloidosis, infections, or plasma cell infiltration in patients with multiple myeloma. In our case, the patient was diagnosed with infectious pericarditis because the pericardial fluid was purulent and Morganella morganii was isolated from the fluid. No myeloma cells were detected in the fluid. We suspect that the patient developed pericardial infection as a result of hematogenous spread because Morganella morganii was isolated from both pericardial and blood cultures. Moreover, we suspect that the primary focus of the infection was the intestines because Morganella morganii is part of the normal flora of the intestine, and the patient had early gastrointestinal symptoms including several bouts of diarrhea prior to the onset of the pericarditis. The prognosis of purulent pericarditis remains poor, primarily due to the lack of prompt recognition and initiation of treatment. Intravenous antimicrobial therapy should be started as soon as the diagnosis of purulent pericarditis is suspected, and surgical drainage should always be considered to relieve cardiac tamponade.

In conclusion, we report a very rare case of purulent pericarditis with cardiac tamponade caused by Morganella morganii. Prompt institution of antibiotic therapy and pericardial drainage resulted in a favorable outcome for our patient.

References

S. Sica, A. Di Mario, P. Salutari et al., “Morganella morganii pericarditis after resolvent splenectomy for immune pancytopenia following allogeneic bone marrow transplantation for acute lymphoblastic leukemia,” Clinical Infectious Diseases, vol. 21, no. 4, pp. 1052–1053, 1995.

Z. T. Yang, M. Lecuit, F. Suarez et al., “Morganella morganii pericarditis 3 years after allogenic bone marrow transplantation for mantle cell lymphoma,” Journal of Infection, vol. 53, no. 5, pp. e223–e225, 2006.

Y. K. Cho, H. Kook, Y. J. Woo, Y. Y. Choi, J. S. Ma, and T. J. Hwang, “Morganella morganii pericarditis in a child with X-linked agammaglobulinemia,” Pediatrics International, vol. 52, no. 3, pp. 489–491, 2010.

W. C. Tsai and L. K. Chang, “Morganella morganii causing solitary liver abscess complicated by pyopericardium and left pleural effusion in a nondiabetic patient,” Journal of Microbiology, Immunology and Infection, vol. 35, no. 3, pp. 191–194, 2002.

G. R. Gemke, M. M. Kaupasa, and F. D. Shusterman, “Two cases of purulent pericarditis as complication of myocardial infarction,” Klinicheskaya Meditsina, vol. 78, no. 2, pp. 55–56, 2000.

M. E. Falagas, P. K. Kavvadia, E. Mantadakis et al., “Morganella morganii infections in a general tertiary hospital,” Infection, vol. 34, no. 6, pp. 315–321, 2006.

C. E. Cox, “Aztreonam therapy for complicated urinary tract infections caused by multidrug-resistant bacteria,” Reviews of Infectious Diseases, vol. 7, supplement 4, pp. S767–771, 1985.

C. McDermott and J. M. Mylotte, “Morganella morganii: epidemiology of bacteremic disease,” Infection Control, vol. 5, no. 3, pp. 131–137, 1984.

H. Isobe, K. Motomura, K. Kotou, H. Sakai, M. Satoh, and H. Nawata, “Spontaneous bacterial empyema and peritonitis caused by Morganella morganii,” Journal of Clinical Gastroenterology, vol. 18, no. 1, pp. 87–88, 1994.

R. D. Isaacs and R. B. Ellis-Pegler, “Successful treatment of Morganella morganii meningitis with pefloxacin mesylate,” Journal of Antimicrobial Chemotherapy, vol. 20, no. 5, pp. 769–770, 1987.

B. N. Kim, N. J. Kim, M. N. Kim, Y. S. Kim, J. H. Woo, and J. Ryu, “Bacteraemia due to tribe proteeae: a review of 132 cases during a decade (1991–2000),” Scandinavian Journal of Infectious Diseases, vol. 35, no. 2, pp. 98–103, 2003.