Purulent Pericarditis

The author shares their first hand account here:

History

A 46 year-old white male patient presented to the hospital with fatigue and dyspnea. He had a history of chronic back pain for which he takes ibuprofen. He also had a remote history of splenectomy following a motor-vehicle accident. 

The patient smokes marijuana occasionally, but does not inject illicit drugs. He has no history of alcoholism. He was born in the United States and has never been outside the country. He has no significant family history.

Figure 1. Electrocardiogram revealing supraventricular tachycardia with repolarization abnormality.

Physical Examination

The patient was afebrile with a blood pressure of 140/98 mm Hg and heart rate around 150 beats per minute. Heart sounds were distant and no murmur or rub was noted. Pulses were irregularly irregular. The patient had mild jugular venous distension, but the inspiratory decrease in systolic blood pressure was not exaggerated. Breath sounds were decreased at the bases with faint crackles. The rest of his physical exam was normal.

Figure 2. Chest X-ray showing a marked enlargement of the cardiomediastinal silhouette.

Laboratory, Imaging, and Biopsy Results

Laboratory tests revealed a hemoglobin of 11.9 g/dl, white cell count 9.5 K/uL, creatinine 1.96 mg/dl, B-type natriuretic peptide 794 pg/mL, and erythrocyte sedimentation rate 18 mm/hr. Electrocardiogram showed tachycardia with no ST-segment elevation (Figure 1). Chest radiography was abnormal (Figure 2) and subsequently led to a computed tomography (CT) of the chest (Figure 3).

Figure 3. CT of the chest showing a large pericardial effusion and bilateral pleural effusions.

Outcome of the Case

A bedside echocardiogram in the emergency department revealed a large pericardial effusion with early tamponade. Immediate pericardiocentesis was performed with drainage of one liter of purulent fluid (Figure 4). Pericardial fluid culture as well as two peripheral blood cultures grew Streptococcus pneumoniae. The organism was intermediately resistant to penicillin but was sensitive to cephalosporins. 

Figure 4. Pericardiocentesis with purulent fluid drainage.

Thoracentesis was also performed revealing transudative and sterile pleural fluid. The patient was initially treated with vancomycin and meropenem, which was de-escalated to ceftriaxone following return of susceptibilities. Pericardial catheter drainage gradually decreased, and the catheter was removed after three days. Human immunodeficiency virus serology, hepatitis serology, and Tuberculin skin test were all negative. Antinuclear antibody titer was normal. Repeat CT of the chest after one week demonstrated only traces of pericardial fluid. 

Antibiotic therapy was continued for 4 weeks, and repeat echocardiography after six weeks was normal.

Discussion

In developed countries, most of the acute pericarditis cases are due to viral or auto-immune etiologies and usually have a benign course. Bacteria, such as S. pneumoniae, are becoming a rare etiology.^1-3

Purulent pericarditis is often secondary to hematogenous spread from a distant site (such as pneumonia or empyema) or a direct extension of a thoracic infection.^3,4 As with our patient, primary bacterial pericarditis when no other infectious focus is identified is extremely rare.^1,5 Staphylococcus aureus and S. pneumoniae are the most common bacterial microoragnisms.^3,4 Mycobacterial and fungal etiologies should also be considered if the patient is immunosuppressed or has an unusual exposure.⁴

Post-splenectomy patients are at high risk for infections by encapsulated organisms including S. pneumoniae. Vaccination can reduce the risk of overwhelming post-splenectomy infections. Our patient did not have a primary care provider and could not recall if he received the pneumococcal vaccine. 

Diagnosis

Purulent pericarditis is often an acute infection with a rapidly fatal outcome if untreated. Fever, dyspnea, and chest pain are the most common symptoms.^3,4 These systemic signs of sepsis may not be prominent if the patient is immunosuppressed or on non-steroidal anti-inflammatory drugs. Typical physical examination findings of acute pericarditis, such as friction rub, are not always present.^3,4 Also, electrocardiography may not show the characteristic ST segment elevation.^3,4 Therefore, the diagnosis is challenging and can be easily missed. Definite diagnosis requires urgent pericardial fluid drainage for analysis and cultures.

Treatment

Appropriate treatment should include both immediate drainage of the pericardium and antibiotic administration.⁶ Pericardiocentesis with indwelling catheter placement is a minimally invasive diagnostic and therapeutic procedure that was successful in the management of our patient, as well as other cases of purulent pericarditis.^4,7,8 

However, incomplete drainage is a potential complication of this approach and may increase the risk of subsequent constrictive pericarditis.³ Repeat imaging to ensure complete and permanent drainage of the pericardial effusion is recommended. Open surgical drainage should be performed when percutaneous catheter fails to completely drain the effusion. Other indications for surgical intervention include loculated effusions and recurrence of the tamponade.⁶ 

Subxiphoid pericardiotomy is preferable and the most effective surgical treatment.^6,9 Surgical mortality can be as high as 8%.⁶ 

Empiric antibiotics covering both gram-positive, in particular methicillin-resistant S. aureus, and gram-negative organisms are appropriate. Antibiotics can be tailored once the microorganism is identified. Therapy should be continued for 2 to 4 weeks and until the resolution of fever and all signs of infection.

In the post-antibiotic era, purulent pericarditis remains an often overlooked medical and surgical emergency. Diligence in the recognition and management can be life-saving. ■

References:

1. Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56(10):623-630.
2. Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol. 1995;75(5):378-382.
3. Sagristà-Sauleda J, Barrabés JA, Permanyer-Miralda G, et al. Purulent pericarditis: review of a 20-year experience in a general hospital. J Am Coll Cardiol. 1993;22(6):1661-1665.
4. Rubin RH, Moellering RC Jr. Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med. 1975;59(1):68.
5. Keersmaekers T, Elshot SRE, Sergeant PT. Primary bacterial pericarditis. Acta Cardiol. 2002;57:385-387.
6. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary: The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25(7):587.
7. Ligtenberg JJ, van der Werf TS, Zijlstra JG, et al. Non-surgical treatment of purulent pericarditis, due to non-encapsulated Haemophilus influenzae, in an immunocompromised patient. Neth J Med. 1999;55(3):151-154.
8. Karp R, Meldahl R, and McCabe R. Candida albicans purulent pericarditis treated successfully without surgical drainage. Chest. 1992;102(3):953-54.
9. Little W, Freeman G. Pericardial disease. Circulation. 2006;113(12):1622-1632.