LIGHTS AND EMPYEMA CRITERIA FOR THE DIAGNOSIS OF PURULENT PERICARDITIS

Abstract

SESSION TITLE: Fellows Disorders of the Mediastinum Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Purulent pericarditis incidence has declined significantly, though some cases emerge sporadically. Here we present a case of cardiac tamponade secondary to pericardial effusion. The fluid analysis was consistent with complicated pericardial effusion with parameters comparable to exudative pericardial effusion and empyema CASE PRESENTATION: 45 year old male, presented with fever, chest pain, and shortness of breath. Vital signs with BP of 102/62, MAP of 75 mmHg, HR 107 BPM, tachypnea at 32 BPM, Oxygen saturation at 82% on room air, and fever of 101.3 F orally. Physical exam showed a male in mild distress, muffled heart sounds, absent air entry on right lower lung zone with dull percussion note, otherwise unremarkable. Lab workup (table 1A) showed leukocytosis, lactic acidosis, acute hepatitis, coagulopathy. (ECG) (Image 1A) with ST elevations in inferior and lateral leads, PR depression in inferior, septal and lateral leads, PR elevation in aVR, and Spodick's sign. Chest XRay (Image 1B) with enlarged cardiac silhouette, right lower lobe airspace disease, and effusion. Patient was started on Empiric antibiotics. Transthoracic ECHO showed thick circumferential pericardial effusion, stranding, early tamponade, with septation observed (Image 2) A pericardial drain was inserted, and fluid analysis was consistent with infected complicated effusion that met light’s criteria for exudative effusion and complicated infected effusion (table 1B) he was treated in a similar fashion to complicated pleural effusion. DISCUSSION: Diagnosis of purulent pericardial effusion is mainly based on fluid analysis showing elevated WBC ranging from 6000 to 240,000 with predominant neutrophilia, elevated protein, and low glucose. Our patient's fluid analysis was comparable to empyema in terms of low pH, low glucose, elevated LDH, positive culture, and thick, yellow, dusky appearance. We treated him similarly to empyema with a pericardial drain and directed antimicrobial therapy with complete resolution. The literature review revealed that light’s criteria applied to pericardial effusion yielded a diagnostic efficiency of 94%, with a sensitivity and specificity in identifying exudates of 98% and 72%, respectively (1). Sensitivity for detecting exudates was high for fluid total protein >3.0 g/dL (97%), fluid to serum protein ratio >0.5 (96%), fluid lactate dehydrogenase ratio >0.6 (94%), and fluid to serum glucose ratio <1.0 (85%). None of these was specific (2). Pericardial fluid pH discriminated between inflammatory (pH 7.06 ± 0.07) and noninflammatory (pH 7.42 ± 0.06) (3) CONCLUSIONS: Clear criteria to differentiate between transudation or exudative pericardial effusions are not well described, utilization of Light's criteria and criteria diagnostic for complicated pleural effusions when applied to pericardial effusions in the right context can be of great diagnostic value to help direct medical therapy. Reference #1: Pleural, peritoneal and pericardial effusions – a biochemical approach, Lara Milevoj Kopcinovic, and Jelena Cule, Biochem Med (Zagreb). 2014 Feb; 24(1): 123–137. DOI: 10.11613/BM.2014.014 Reference #2: The Usefulness of Diagnostic Tests on Pericardial Fluid, David G. Meyers et al, Chest Journal Volume 111, Issue 5, Pages 1213–1221, DOI: https://doi.org/10.1378/chest.111.5.1213 Reference #3: Clinical utility of pericardial fluid pH determination, The American Journal of Internal medicine, VOLUME 75, ISSUE 6, P1077-1079, DECEMBER 01, 1983 DOI: https://doi.org/10.1016/0002-9343(83)90892-6 DISCLOSURES: No relevant relationships by Mohammed Aljasmi, source=Web Response No relevant relationships by Rami Batarseh, source=Web Response No relevant relationships by Christopher Lipinski, source=Web Response