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714 test for hepatitis C was positive. After 10 days of incubation, pericardial cultures ultimately re‐ vealed Actinomyces israelii, Aggregatibacter actinomycetemcomitans, and Fusobacterium nucleatum identified by the MALDI TOF mass spec‐ trometer (VITEK MS, bioMérieux, Marcy l’ Étoile, France) (FIGURE 1B and 1C). Transesophageal echo‐ cardiography showed a large hypoechoic mass in the right ventricular wall, which was suggestive of myocardial abscess (FIGURE 1D). After multidis‐ ciplinary discussion, a conservative therapeutic strategy was chosen, as a surgery would have re‐ quired use of prosthetic material that posed im‐ minent risk of reinfection in the active intrave‐ nous drug user. Targeted antibiotic treatment in‐ cluding piperacillin / tazobactam (4.5 g 4 times a day) against the bacteria mentioned above and linezolid (600 mg 3 times a day) for a possible Enterococcus faecium infection in our critically ill patient with several vascular catheters in place led to clinical improvement and the patient was Pericardial empyema is observed in about 1% of all cases of pericarditis. Staphylococci and strep‐ tococci are the most relevant pathogens, but an‐ aerobic bacteria may also be present in dental or esophageal diseases.1 A 52 ‐year ‐old man was admitted to our hospital after he had collapsed at home. He presented with dyspnea, blood pres‐ sure of 86/44 mm Hg, and oxygen saturation of 80% on supplemental oxygen delivered at a flow rate of 15 l/min via a nonrebreather mask, and thus required immediate endotracheal intubation, mechanical ventilation, and catecholamine ther‐ apy. Clinical examination showed extensive den‐ tal caries, jugular vein distention, and several in‐ jection marks on both arms, indicative of intra‐ venous drug abuse. The medical history indicat‐ ed that he was on opioid substitution treatment and suffered from recurring epileptic seizures. Computed tomography revealed caverns in both lungs and massive pericardial effusion (FIGURE 1A). Pericardiotomy and external drainage were per‐ formed and 1 l of pus was removed. Laboratory analysis showed a serum lactate level of 19 mmol/l (normal range, 0.5–2.2 mmol/l), a white blood cell count of 20.2 G/l (normal range, 4.4–11.3 G/l), a C ‐reactive protein level of 132 mg/l (nor‐ mal range, <5.0 mg/l), and a procalcitonin level of 0.27 ng/l (normal range, 0.00–0.50 ng/l). Initially, the patient scored 12 points on the Sequential Or‐ gan Failure Assessment (previously Sepsis ‐related Organ Failure Assessment) score and received imi‐ penem/cilastatin (1 g 4 times a day) and fosfomy‐ cin (4 g 3 times a day). Extensive microbiological examinations for mycobacteria, the polymerase chain reaction test for hepatitis B and HIV, urine and blood cultures, Ziehl–Neelsen ‐stain, galac‐ tomannan test, and (1,3)‐ß ‐D‐glucan assay were negative, whereas the polymerase chain reaction CLINICAL IMAGE

Pericardial empyema due to Actinomyces israelii, Aggregatibacter actinomycetemcomitans, and Fusobacterium nucleatum