Purulent pericarditis in advanced thymoma: A case report

Abstract

Thymoma is the most common primary anterior mediastinum mass with various clinical manifestations, and one of the manifestations is pericardial effusion. While pericardial effusion in thymoma is usually serous, it can become purulent when an infection occurs in a nearby organ, albeit rare. In this report, we present a rare case of a 27-year-old woman who had purulent pericarditis secondary to an advanced thymoma. The patient came to the emergency department with the chief complaints of worsening chest discomfort, non-productive cough, and fever in the past 2 weeks. The patient was diagnosed with thymoma 5 months prior. Based on the examinations, it was discovered that the patient had pericarditis. After the pericardiocentesis was performed and the fluid was examined, the patient was diagnosed with purulent pericarditis secondary to thymoma. The patient was then treated with intravenous antibiotic and pericardial drain. Unfortunately, the patient's condition deteriorated, and the patient died on the fifth day of hospitalization. This case highlights an infrequent but potentially life-threatening complication of thymoma. In addition, thymic pathologies should be included as a rare etiology in the differential diagnosis of purulent pericardial effusion.

Full text

Radiology Case Reports 17 (2022) 3996–4000
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/radcr
Case Report
Purulent pericarditis in advanced thymoma: A case
report
✩
Jordan Bakhriansyah, MD
a , b , 1 , ∗
, I Gede Parama Gandi Semita, MD
c , e , 1 , ∗
,
I Gde Rurus Suryawan, MD
c
, Yusuf Azmi, MD
c
, Irfan Deny Sanjaya, MD
d
,
Risma Ikawaty, MD
a
, David Nugraha, BM
e
, Firas Farisi Alkaff, MD
f , g
a
Faculty of Medicine, Universitas Surabaya, Jalan Raya Rungkut, Surabaya 60293, East Java, Indonesia
b
Department of Cardiology and Vascular Medicine, Husada Utama Hospital, Surabaya, Indonesia
c
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga –Dr. Soetomo
General Academic Hospital, Surabaya, Indonesia
d
Department of Radiology, Faculty of Medicine Universitas Airlangga –Dr. Soetomo General Academic Hospital,
Surabaya, Indonesia
e
Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
f
Division of Pharmacology and Therapy, Department of Anatomy, Histology, and Pharmacology, Faculty of Medicine
Universitas Airlangga, Surabaya, Indonesia
g
Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The
Netherlands
          
Article history:
Received 8 June 2022
Revised 25 July 2022
Accepted 28 July 2022
Keywords:
Thymoma
Pericardial effusion
Mediastinal mass
Pericardiocentesis
Case report
       
Thymoma is the most common primary anterior mediastinum mass with various clinical
manifestations, and one of the manifestations is pericardial effusion. While pericardial ef-
fusion in thymoma is usually serous, it can become purulent when an infection occurs in
a nearby organ, albeit rare. In this report, we present a rare case of a 27-year-old woman
who had purulent pericarditis secondary to an advanced thymoma. The patient came to
the emergency department with the chief complaints of worsening chest discomfort, non-
productive cough, and fever in the past 2 weeks. The patient was diagnosed with thymoma
5 months prior. Based on the examinations, it was discovered that the patient had pericardi-
tis. After the pericardiocentesis was performed and the uid was examined, the patient was
diagnosed with purulent pericarditis secondary to thymoma. The patient was then treated
with intravenous antibiotic and pericardial drain. Unfortunately, the patient’s condition de-
teriorated, and the patient died on the fth day of hospitalization. This case highlights an
infrequent but potentially life-threatening complication of thymoma. In addition, thymic
✩ Competing Interests: None declared.
∗Corresponding authors .
E-mail addresses: jordan.kardio@staff.ubaya.ac.id (J. Bakhriansyah), paramagandi-2018@fk.unair.ac.id (I.G.P.G. Semita).
1 These authors contributed equally and are shared rst author.
https://doi.org/10.1016/j.radcr.2022.07.099
1930-0433/© 2022 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the
CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

Radiology Case Reports 17 (2022) 3996–4000 3997
pathologies should be included as a rare etiology in the differential diagnosis of purulent
pericardial effusion.
© 2022 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
This is an open access article under the CC BY license
( http://creativecommons.org/licenses/by/4.0/ )
Introduction
Thymoma is the most common primary anterior medi-
astinum mass derived from the thymic epithelium [1] . The
progression of this tumor is slow and usually detected inci-
dentally during radiographic imaging [2] . Their clinical man-
ifestations are usually unpredictable and varies from asymp-
tomatic to advanced symptoms such as paraneoplastic syn-
drome due to thoracic metastases [3] . Several symptoms re-
lated to the adjacent structure could be triggered caused by
the local growth and invasion of the tumor, including pericar-
dial effusion [3] . While the type of uid of the pericardial effu-
sion in this condition is usually serous, the effusion uid can
become purulent when an infection occurs in a nearby organ.
In this report, we present a rare case of purulent pericarditis
secondary to upper respiratory tract infection in a patient with
thymoma.
Case presentation
A 27-year-old woman presented to the emergency depart-
ment with chief complaints of progressive chest discomfort,
non-productive cough, and fever in the past 2 weeks. The pa-
tient was diagnosed with thymoma stage III (Masaoka-Koga)
type 3B (WHO) 5 months prior and was recently underwent
chemotherapy with cisplatin-etoposide regiments for 3 cycles.
On physical examination, the patient’s vital signs were
as follows: blood pressure 110/70 mmHg, respiratory rates 28
times / min, heart rate 145 beats per min, right axillary tem-
perature 37.7 °C, and oxygen saturation 95% at room air. No
jugular venous distention was observed. The percussion on
the left anterior chest was dull, and the vesicular sound was
reduced. Rhonchi, wheezing, or abnormal heart sounds were
absent during auscultation. The abdomen was soft and non-
tender, and the liver and spleen were not palpable. Laboratory
evaluation revealed elevated white blood cell (17.8 ×10
3
/ μL,
reference range 5-10.0 ×10
3
/ μL) with neutrophils dominance
(95%, reference range 55%-70%), elevated liver enzymes (as-
partate transaminase190 IU/L, reference range 0-35 IU/L; ala-
nine transaminase119 IU/L, reference range 4-36 IU/L), and
elevated C-reactive protein level (14.2 mg/L, reference range
< 10.0 mg/L).
Electrocardiography evaluation revealed sinus tachycardia,
right axis deviation, and low voltage in the precordial leads
( Fig. 1 ). Chest X-ray showed mediastinal widening with peri-
cardial effusion and diffuse apical consolidation suggesting
pneumonia ( Fig. 2 ). Tran s t h orac i c echocardiography demon-
strated a massive pericardial effusion (21 mm) at the poste-
rior without a sign of right ventricle chamber collapse ( Fig. 3 ).
Contrast-enhanced chest computed tomography scan (CT-
scan) revealed a mass sized 9.4 ×12.9 ×11.4 cm with irregular
borders located at the anteromedial left mediastinum, as high
as the second to fourth thoracal vertebrae. The tumor was also
attached to the posterior sternum, left upper hemithorax wall,
ascending aorta, aortic arch, left pulmonary artery, and left
carotid artery ( Fig. 4 ).
Pericardiocentesis with uoroscopy guidance was then
performed under local anesthesia, and 500 ml of thick pus
was successfully aspirated ( Fig. 5 ). The pericardial uid anal-
ysis conrmed a purulent effusion, with elevated pericardial
leucocyte count (177 ×10
3
/ μL, reference range < 10 ×10
3
/ μL),
low pericardial to serum glucose ratio (0.09, reference range
> 0.3), elevated pericardial protein (4.8 g/dL, reference range
> 3 g/dL), and elevated pericardial lactate dehydrogenase (963
U/L, reference range < 200 U/L). There was no malignant cells
in the pericardial cytology examination. Pericardial uid cul-
ture grew Staphylococcus aureus , while blood culture did not
grow.
Based on the ndings, the patient was diagnosed with pu-
rulent pericardial effusion secondary to stage III type B3 thy-
moma. The patient was treated with intravenous meropenem
1 gram thrice daily, and the pericardial drain was placed on the
site of pericardiocentesis. However, 2 days afterward, the pa-
tient’s condition deteriorated. The pericardial drain was not
functioning properly due to loculation, and the patient was
Fig. 1 – Twelve-lead electrocardiography reveals a sinus tachycardia of 150 beats per minute, right axis deviation, and a low
voltage on precordial leads.

3998 Radiology Case Reports 17 (2022) 3996–4000
Fig. 2 –An anterior posterior (A) and lateral (B) view of chest X-ray show mediastinal widening with massive pericardial
effusion.
Fig. 3 – Transthoracic echocardiography demonstrates a massive pericardial effusion (21 mm) at the posterior, without any
sign of right ventricle chamber collapse.
unt for further procedures. The patient was then died on the
fth day of hospitalization.
Discussion
Herein, we present a case of a large purulent pericardial effu-
sion as a manifestation of an advanced thymoma. To the best
of our knowledge, no prior report has been published regard-
ing this. The incidence of thymoma is rare with only 0.15 cases
per 100,000 and is commonly found in middle age and peaks in
the seventh decade of life [ 4 ,5 ]. However, thymoma appeared
at a considerably young age in our case.
The anterior mediastinum is a wholly shielded body cav-
ity making small tumors undetected and undiagnosed. Gen-
erally, thymoma is detected when it is large enough or clini-
cally manifests as local symptoms related to the involvement
of surrounding structures, such as chest discomfort, dyspnea,
hoarseness, superior vena cava syndrome. When the tumor
is invasive, pericardial involvement can be found in around
one-third of the cases [ 6 ,7 ]. Most thymoma cases are usually
found through CT-scan, and this modality helps differentiate
between thymoma and thymic cancer [8] . On CT-scan ndings,
a focal oval soft tissue mass with sharply demarcated round
found in the anterior mediastinum compartment is strongly
suggestive of thymoma [9] . In our cases, the CT-scan showed a
heterogeneously irregular mass at the anterior mediastinum
that invaded mediastinal fat and adhered to the left upper
hemithorax and the adjacent vessels.
Pericardial effusion is an uncommon clinical manifesta-
tion and presents in approximately 20% of thymoma patients

Radiology Case Reports 17 (2022) 3996–4000 3999
Fig. 4 – Chest computed tomography with intravenous contrast during the venous phase. (A) The axial mediastinal window
shows that the anterior mediastinum contains a heterogeneously enhancing irregular mass. The mass has invaded
mediastinal fat and adhered to adjacent vessels such as the aorta and pulmonary artery (arrow). The mass also adhered to
the left upper hemithorax wall (open arrow). (B) The coronal mediastinal window shows the inltration of the mass to the
pericardium and epicardial fat (arrow). Also, note the presence of the left pleural effusion (asterisk).
Fig. 5 –A pericardial uid aspiration reveals thick pus in
the pericardial space.
[10] . Pericardial effusion in our case was not caused by the
primary or secondary complication of the tumor in the peri-
cardium since the uid cytology examination revealed no sign
of malignant cell. We therefore hypothesized that the pericar-
dial effusion was caused by the circulatory system suppres-
sion and lymphatic drainage obstruction. Lym pha t ic system
in the heart and pericardium has a vulnerable isthmus-like
section near the aortic root. The size and extent of the isth-
mus are not well delineated and narrow enough to cause car-
diac lymphatic blockage. When there is a tumor that is located
in that area, it may cause blockage of the lymphatic ow, lead-
ing to the extravasation of the lymphatic uid to the pericar-
dial area [11] . Next to that, when a tumor metastases to the
mediastinal lymph node, it may obstruct the ow of the lym-
phatic drainage, causing accumulation and also extravasation
of lymphatic uid to the pericardial area [12] .
Bacterial pericarditis is rarely found in the era of antibi-
otics, which only accounted for a less than one percent of all
cases [13] . The cause of bacterial pericarditis is secondary to
adjacent spreading of intrathoracic infection or by hematoge-
nous spread [14] . In our case, we believed that the bacteria was
originally from the pneumonia. Various bacteria may respon-
sible in causing purulent pericarditis, with Staphylococcus au-
reus as the most common pathogen [15] . This is in line with
the bacteria that we found in the pericardial uid of our pa-
tient.
As the mortality rate of patients with pericarditis sec-
ondary to thymoma is high [ 10,16–19 ], aggressive and ade-
quate treatments are needed. Previous studies found that pa-
tients receiving pericardiectomies had longer median survival
time compared to standard supportive care and pericardio-
centesis or radio-chemotherapy alone [ 11 ,20 ]. However, our
patient had a higher mortality risk because of the advanced
stage III type B3 thymoma [21] . Thus, it is not an option for
our patient to undergo such procedures.
Conclusion
In rare instances, a case of advanced thymoma can lead to
more severe complications such as purulent pericardial effu-

4000 Radiology Case Reports 17 (2022) 3996–4000
sion with chest discomfort and non-productive cough as the
clinical manifestations. Considering the nature of this malig-
nancy and its life-threatening prognosis, early diagnosis and
prompt management of purulent pericarditis are essential.
Patient consent
Written informed consent was obtained from the patient’s
husband for publication of this case report and the accom-
panying images.
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