Bacterial Pericarditis Causing Cardiac Tamponade in a Patient with No Primary Source of Infection

Abstract

Introduction Bacterial Pericarditis is a rare entity accounting for Case Description 73 year old male with history of coronary artery disease presents with pleuritic chest pain and dyspnea since 2 days. On arrival, he was hemodynamically stable. EKG showed changes consistent with acute pericarditis. Echo showed moderate pericardial effusion without tamponade and normal systolic/diastolic function. Patient was treated with colchicine, NSAIDS could not be given due to acute kidney injury. His home dose of aspirin and clopidogrel were continued. Overnight, patient decompensated with persistent tachycardia, tachypnea and hypoxia. He started spiking fevers with worsening leucocytosis. Echo showed moderate pericardial effusion with signs of cardiac tamponade. Urgent pericardiocentesis was done and 250 mL of serosanguinous fluid was removed and a pigtail catheter was left in situ. His antiplatelet agents were discontinued to prevent hemorrhagic pericardial effusion. Methicillin sensitive Staphylococcus aureus was detected in cultures of pericardial fluid and blood. His antibiotic was deescalated to intravenous nafcillin. Echo post procedure showed small pericardial effusion with fibrinous echogenic material. His pericardial drain was not draining enough and was removed the next day. He started developing moderate left sided pleural effusion, likely an extension of pericardial inflammation. A small bore pleural catheter was placed in left pleural space for drainage. He had to undergo pericardectomy for definitive drainage and a chest tube was placed in right pleural cavity for drainage. Transesophageal echocardiogram demonstrated no further pathology. Repeat echo and CT-chest did not show any effusions, so pleural drains were removed on 6th day and patient was doing well. Discussion Purulent pericarditis presents as an acute illness characterized by fever in all patients, chest pain in 25-37% of patients. Bacterial pericarditis is usually not a primary infection, but occurs as a complication of underlying infection. Risk factors are immunosuppression, chest injuries, and chronic kidney disease with hemodialysis, diabetes mellitus and alcoholism. About 15% of patients with purulent pericarditis can develop cardiac tamponade. Typically small effusions accumulate quickly and develop tamponade. Large effusions can accumulate slowly allowing the pericardial sac to expand. Treatment is drainage of pus along with antibiotic therapy. Pericardiocentesis may be sufficient but in case of recurrent effusion or poor drainage of thick loculated fluid, pericardiotomy and pericardial window with manual lysis of adhesions and loculations allowing complete drainage is required. Survival in purulent pericarditis depends on early empiric antibiotic therapy and pericardial drainage.