Abstract 17182: A Case of Purulent Pericarditis in the Setting of Streptococcal Pneumonia

Abstract

Introduction: Purulent pericarditis was a prevalent complication of streptococcal pneumonia prior to antibiotic era, but uncommon in the modern age. Purulent pericarditis is characterized by gross pus or microscopic purulence localized in the pericardial space. Case Presentation: A case of a 68-year-old male presenting with dyspnea, chest pain, left knee pain and edema. Medical history was significant for hypertension, diabetes, hypothyroidism. He developed respiratory failure due to pneumonia and was treated in intensive care unit. S. pneumoniae bacteremia and septic arthritis with isolation of the same pathogen from synovial fluid were diagnosed. Initial ECG showed diffuse ST elevations suggestive of pericarditis, so TTE was obtained. It showed a small, free flowing pericardial effusion along RV free wall with no evidence of hemodynamic compromise. Serial TTEs were done showing increasing size of pericardial effusion. On day 7 of hospitalization patient had several episodes of atrial fibrillation with RVR complicated by hypotension. A subsequent TTE showed a large, free-flowing pericardial effusion with signs of early tamponade. Patient underwent urgent pericardiocentesis with drainage of one liter of purulent fluid and placement of pericardial drain. Fluid analysis confirmed purulent pericarditis, gram stain and cultures were negative. Repeat TTE showed a trivial pericardial effusion and a 2.7mm mass suspicious for vegetation on the mitral valve with moderate MR, confirmed by TEE. CT surgery recommended 6 weeks of antibiotics with no surgical intervention. Patient was discharged to a skilled nursing facility for a prolonged IV antibiotic course with a follow up with cardiology. Conclusion: This case shows purulent pericarditis in the setting of pneumonia complicated by bacteremia, infective endocarditis, and septic arthritis. Although rare, purulent pericarditis is a life-threatening disease, so timely diagnosis and treatment are of essence.