Massive Iatrogenic Pneumopericardium Complicating MDR-TB Pericarditis with Superimposed Citrobacter Suppurative Pericarditis: A Case Report

Abstract

Background: Tuberculous pericarditis is a well-recognized cause of pericardial effusion in TB-endemic regions, but suppurative superinfection with Citrobacter species, an opportunistic Gram-negative organism, is rarely reported. Iatrogenic pneumopericardium following pericardiocentesis is also an exceedingly rare procedural complication. To our knowledge, the coexistence of multidrug-resistant tuberculosis (MDR-TB) pericarditis, Citrobacter superinfection, and iatrogenic pneumopericardium in a young immunocompetent patient has not been previously described. Case Summary: A 20-year-old male laborer presented to the Emergency Department with sudden, severe, non-radiating left chest pain and transient loss of consciousness, preceded by four months of fever, night sweats, dry cough, dyspnea, and weight loss. There’s a positive family history of TB. He was tachycardic and hypertensive. Labs showed leukocytosis with neutrophilia, elevated CRP and creatinine, hyponatremia, and mild anemia. Echocardiography revealed massive circumferential pericardial effusion with tamponade (LVEF 65%). Emergency pericardiocentesis via subxiphoid approach drained 200 mL of turbid fluid, confirming a neutrophilic suppurative exudate. Culture grew Citrobacter species sensitive to piperacillin-tazobactam and meropenem. Post-procedural CT revealed massive iatrogenic pneumopericardium, and abdominal ultrasound showed ascites, suggesting TB-related polyserositis. Piperacillin-tazobactam failed for 15 days. Pericardiocentesis was repeated, and escalation to meropenem produced improvement. Recurrent effusion (25 mm, LVEF 55%) raised concern for constrictive pericarditis. Extended cultures and susceptibility testing confirmed MDR-TB, and multidrug therapy was initiated alongside meropenem, resulting in significant improvement. The patient was discharged with a pericardiectomy planned at follow-up. Conclusion: This case illustrates a rare, diagnostically deceptive presentation of MDR-TB pericarditis superinfected with Citrobacter, complicated by massive iatrogenic pneumopericardium. Neutrophilia from bacterial superinfection can mask expected TB-associated lymphocytosis, so CBC alone should not exclude TB. Post-procedural CT is essential when deterioration follows pericardiocentesis. Organism-specific antibiotics with timely escalation to stronger regimens are critical to management. Key Words: Pneumopericardium, MDR-TB Pericarditis.