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Fatal unruptured myocardial abscesses

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A 67 year old man was admitted with a two week history of intermittent lower chest pain. He had been treated for a bacteriologically confirmedEscherichia coli urinary tract infection six months previously. On admission he was apyrexial, normotensive, and an echocardiogram showed a 1–2 cm pericardial effusion with globally impaired left ventricular systolic contraction. He subsequently had a cardiac arrest due to electromechanical dissociation, and a pericardiocentesis of 20 ml of blood stained fluid regained cardiac output. He died of circulatory failure that evening. All blood and pericardial fluid cultures were subsequently negative.

At necropsy there was a purulent pericardial effusion. The left ventricle was almost entirely replaced by multiple confluent abscesses, but without discernible perforation, and the right ventricle was normal. The heart valves were normal with no vegetations. There was moderate to severe occlusive coronary disease in all three arteries. A small right kidney had multiple small papillary abscesses. Bacteriological examination of the left ventricular and renal abscesses grew coliforms.

In cases of severe septicaemia myocardial abscesses are often clinically silent and only found at necropsy. Our patient had presented to his general practitioner with a urinary tract infection six months before hospital admission and remained clinically well in the intervening period. The finding of coliforms in both the left ventricular and renal abscesses suggests that subacute renal tract infection resulted in a bacteraemia with seeding of the myocardium leading to multiple unruptured myocardial abscesses.