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Streptococcus pyogenes pericarditis in a healthy adult: a common organism in an uncommon site

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Clinical record

A 64-year-old man presented with progressive dyspnoea, chest pain and rigors 5 days after returning from the United States. This was preceded by a 3-week history of sore throat, left submandibular lymphadenopathy and non-productive cough and fevers, which began while he was overseas.

The patient’s overseas travel was limited to major cities. His past medical history was unremarkable. He did not smoke, consume excessive alcohol or use illicit drugs. The patient did report a dental root infection in the week before travel, which completely resolved following drainage.

On presentation to our hospital, the patient was alert and afebrile but hypotensive with blood pressure of 80/60 mmHg on a peripheral vasopressor infusion. Vital signs included a heart rate of 106 beats/min, respiratory rate of 36 breaths/min and oxygen saturation of 99% on supplemental oxygen (4 L/min). Heart sounds were muffled with no pericardial rub heard. Jugular venous pressure was elevated and his electrocardiogram showed low voltage QRS complexes and saddle-shaped ST elevation laterally (Figure 1).

Inflammatory markers revealed a white cell count of 26.7 × 109/L (reference interval [RI], 4–11 × 109/L) with predominant neutrophilia and a C-reactive protein level of 207 mg/L (RI, < 5 mg/L).