Case Presentation: A 69-year-old immune-competent male presented with one-month history of fatigue and weakness. Patient endorsed decreased oral intake. He also noted dyspnea on exertion, non-productive cough and peripheral edema. Past medical history was significant for coronary artery disease, hypertension and chronic obstructive pulmonary disease (COPD). He was tachycardic but otherwise normal sinus with clear lung sounds. Trace edema was present in the lower extremities. A trans thoracic echocardiogram revealed normal left ventricular (LV) wall thickness with ejection fraction at the low limits of normal 50-55%, a large echo lucent area along the posterior lateral LV and along the right ventricular outflow tract border suggestive of a localized/loculated pericardial effusion vs pericardial cysts without sign of hemodynamic compromise. CT chest revealed a moderate walled off appearing pericardial effusion with significant mass effect on the heart suggestive of early cardiac tamponade. On bedside echo by cardiology, presence of pericardial effusion with tamponade was confirmed, supported by tachycardia and pulsus paradoxus. He underwent urgent pericardiocentesis and 60 milliliters of bloody fluid was removed. Pericardial fluid culture returned positive for Propionibacterium acnes. He completed four weeks of antibiotics with improvement of symptoms.

Discussion: Fatigue, weakness and dyspnea on exertion are common complaints encountered by the hospitalist. Infrequently, does pericardial disease become a top differential unless the typical symptoms of either pericarditis or pericardial tamponade are present. This case illustrates a subacute presentation of pericardial tamponade and an atypical presentation of an infection caused by P. acnes.
Clinical presentation of acute pericardial tamponade is characterized by chest pain, dyspnea and tachypnea. When the presentation is subacute, the clinical course follows a more indolent pattern. In these patients, symptoms such as fatigue and dyspnea are more common. In the case of chronic tamponade, patients may complain of lower extremity edema. In this patient’s clinical presentation, it followed a subacute pattern of pericardial tamponade and progressed to develop rapid hemodynamic compromise.

P. acnes is part of normal flora of the human skin and mucosal surfaces and frequently known as the bacteria that causes acne. It is not often known to infect the pericardium. As rare as it may be, this organism is able to cause infection of the pericardium as stated above and is increasingly being seen to cause invasive disease in patients with prior surgery particularly those with implantable devices such as orthopedic implants and endovascular implants. P. acnes is also recognized as causing infection of CNS shunts. Another case illustrated P. acnes as cause of infective pericarditis and pericardial effusion following an intra-articular steroid injection of the knee. It is important for hospitalists to be aware of the different diseases this seemingly nonthreatening organism can cause.

Conclusions: In conclusion, this case illustrates another example of the virulence that P. acnes can cause and it points out typical symptoms encountered by the hospitalist in a not so typical presentation of pericardial disease. Most standard cultures will not isolate P. acnes as it can take more than five days to grow. We recommend considering P. acnes in differentials in all cases of pericardial effusions, pericarditis, pericardial constriction and pericardial tamponade.