© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12919
Echocardiography
Giant Purulent Pericarditis with Cardiac Tamponade Due to Streptococcus intermedius Rapidly Progressing to Constriction Elif T. Tigen, M.D.,* Ibrahim Sari, M.D.,† Koray Ak, M.D.,‡ Sena Sert, M.D.,† Kursat Tigen, M.D.,† and Volkan Korten, M.D.* *Department of Infectious Diseases, School of Medicine, Marmara University, Istanbul, Turkey; †Department of Cardiology, School of Medicine, Marmara University, Istanbul, Turkey; and ‡Department of Cardiovascular Surgery, School of Medicine, Marmara University, Istanbul, Turkey
Purulent pericardial effusion, although rare, is a life-threatening condition usually produced by the extension of a nearby bacterial infection locus or by blood dissemination in the immune-suppressed subjects or in the course of cardiothoracic surgery. Because clinical features of purulent pericardial effusion are often nonspecific, it can cause delay in diagnosis. Therefore, a high index of suspicion is required for timely diagnosis and management. Herein, we describe a case of giant purulent pericardial effusion due to Streptococcus intermedius with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via parasternal approach, appropriate antibiotics, and pericardiectomy. (Echocardiography 2015;32:1318–1321) Key words: giant purulent pericarditis, pericardial effusion, tamponade, Streptococcus intermedius, constrictive pericarditis
Purulent pericarditis is characterized by purulent pericardial effusion, which is generally produced by the extension of a nearby bacterial infection locus or by blood dissemination.1 Generally clinical presentation is severe and tends to progress to cardiac tamponade and constriction. Herein, we describe a case of giant purulent pericardial effusion due to Streptococcus intermedius with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via parasternal approach, appropriate antibiotics, and pericardiectomy. Case Presentation: A 19-year-old man presented to our emergency department with worsening dyspnea, palpitation, nausea, and abdominal pain for the last several days. His medical history was remarkable for bronchiectasis (diagnosed 7 years ago) and several hospitalizations due to pneumonia (last one 25 days ago). Immediate physical examination revealed cold and sweaty extremities, marked jugular venous distention, diminished heart Address for correspondence and reprint requests: Ibrahim Sari, M.D., Professor in Cardiology, Department of Cardiology, School of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey. Fax: + 90-216-6570695; E-mail: [email protected]
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sounds, abdominal tenderness, and clubbing. Admission vital signs were as follows: blood pressure, 95/73 mm Hg; pulse rate, 139/min; respiratory rate, 26/min; temperature, 36.5 °C; and O2 saturation, 90% on room air. His electrocardiogram was unremarkable except sinus tachycardia. Laboratory values were as follows: hemoglobin level, 10.6 g/dL; white blood cell count, 7100/lL; platelet, 313.000/lL; C-reactive protein, 103 mg/L; aspartate amino transferase, 260 U/L; and alanine amino transferase, ALT:579 U/L. Chest x-ray showed bottle shape cardiomegaly and bilateral costophrenic sinuses were closed. Computed tomography of thorax revealed giant pericardial effusion surrounding all heart and almost obliterating right heart chambers with bilateral pleural effusion (Fig. 1A,B). Transthoracic echocardiography revealed huge pericardial effusion (most prominent in the right ventricular site with more than 5 cm in diameter) surrounding the heart and compressing right atrium and ventricle (Fig. 1C–E, movie clips S1 and S2). There were marked respiratory variations in mitral and tricuspid inflow patterns compatible with tamponade (Fig. 1F). In subcostal view, inferior vena cava was dilated (28 mm), and there was no respiratory variation in its diameter.
Giant Purulent Pericarditis
Because clinical scenario was compatible with tamponade, we performed echocardiography-guided pericardiocentesis via parasternal approach (Fig. 2A). In the first stage, 950 mL straw-colored purulent fluid was evacuated (Fig. 2B) and a pigtail drainage catheter was left in the pericardial cavity. Pericardial fluid glucose was 2 mg/dL, protein 5 mg/dL, LDH 120 U/L, triglyceride 30 mg/dL, and white blood cell count 4150/lL. Repeated pericardial fluid cultures were positive for S. intermedius. We started intravenous ampicillin/sulbactam four times a day. After a total of 2700 mL purulent fluid drainage in 72 hours, obstruction occurred in pigtail catheter (despite irrigation) and it was removed. Although we observed significant clinical and laboratory improvement with the help of pericardiocentesis and antibiotic therapy, control echocardiography revealed salient residual pericardial effusion and marked thickening both in visceral and in parietal pericardium (Fig. 2C–E, movie clips S3 and S4), which was concordant with effusive constrictive pericarditis. Surgical pericardiectomy was performed, which revealed very thick (more than 10 mm) pericardium (Fig. 2F) and resulted in complete relief of symptoms. Six months after the surgery, his control echocardiography was completely normal and he was free of any symptoms.
Discussion: Purulent pericardial effusion, although rare, is a life-threatening condition usually produced by the extension of a nearby bacterial infection locus or by blood dissemination in the immune-suppressed subjects or in the course of cardio-thoracic surgery.1 Because clinical features of purulent pericardial effusion are often nonspecific, it can cause delay in diagnosis. Therefore, a high index of suspicion is required for timely diagnosis and management. The most common cause of purulent pericardial effusion is Staphylococcus aureus and Streptococcus pneumoniae.2 To our knowledge, our case is the third patient in the literature who experiences purulent pericarditis due to S. intermedius.3,4 Streptococcus intermedius is a member of Streptococcus anginosus (milleri) group, which are normally found in normal flora of oral cavity and gastrointestinal tract; however, they can cause abscesses and systemic infections.5,6 In differential diagnosis, we considered chylous pericardial effusion; however, lack of trauma history, low level of triglyceride in pericardial fluid analysis, documentation of S. intermedius in consecutive pericardial fluid cultures, and history of bronchiectasis and repeated pneumonias made us to consider our case as purulent pericardial effusion. Treatment of purulent pericardial effusion consists of drainage of the pericardial fluid and
Figure 1. A,B. Thorax tomography demonstrating giant pericardial effusion surrounding the heart and almost obliterating right heart chambers with bilateral pleural effusion. C–E. Transthoracic echocardiography showing huge pericardial effusion (most prominent in the right ventricular site with more than 5 cm in diameter) surrounding the heart and compressing right atrium and ventricle. F. Marked respiratory variation in the mitral inflow pattern.
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Figure 2. A. Pericardiocentesis procedure via parasternal approach. B. Straw-colored purulent fluid. C–E. Considerable amount of residual pericardial effusion and marked thickening both in visceral and in parietal pericardium. F. Marked thickening of the pericardium (more than 10 mm) during surgical pericardiectomy.
culture-guided antibiotherapy.1,2,7,8 Despite pericardiocentesis and appropriate antibiotic treatment, constrictive pericarditis often complicates the scenario. Although some authors suggest prophylactic surgical pericardiectomy in all patients with purulent pericarditis, it is controversial.1 In our case, because constrictive physiology persisted after pericardiocentesis and appropriate antibiotherapy (considerable amount of residual pericardial effusion, thickened visceral and parietal pericardium, tachycardia, persistent septal bouncing in echocardiography), we performed pericardiectomy. Intrapericardial fibrinolysis and/or irrigation with saline or antibiotics to facilitate dissolution of inflammatory and infectious substances and enhance antibiotic penetration might also be used to minimize the risk of constrictive pericarditis; however, this approach needs more data.9 Generally pericardiocentesis is performed via subxiphoid approach. We performed parasternal pericardiocentesis because it is reported to be simple and more safe than subxiphoid approach.10 Additionally, we were concerned about possible dissemination of the infection to the abdominal cavity. In conclusion, the present paper reports a rare case of giant purulent pericardial effusion due to S. intermedius in a young male with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via paras1320
ternal approach, appropriate antibiotics, and pericardiectomy. References 1. Petcu CP, Dilof R, Bataıosu C, et al: Purulent pericardial effusions with pericardial tamponade – diagnosis and treatment issues. Curr Health Sci J 2013;39:53–56. 2. Maisch B, Seferovic PM, Ristic 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: 587–610. 3. Muto M, Ohtsu A, Boku N, et al: Streptococcus milleri infection and pericardial abscess associated with esophageal carcinoma: report of two cases. Hepatogastroenterology 1999;46:1782–1784. 4. Presnell L, Maeda K, Griffin M, et al: A child with purulent pericarditis and Streptococcus intermedius in the presence of a pericardial teratoma: an unusual presentation. J Thorac Cardiovasc Surg 2014;147:e23–e24. 5. Claridge JE 3rd, Attorri S, Musher DM, et al: Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (“Streptococcus milleri group”) are of different clinical importance and are not equally associated with abscess. Clin Infect Dis 2001; 32:1511–1515. 6. Whiley RA, Beighton D, Winstanley TG, et al: Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infections. J Clin Microbiol 1992;30:243–244. 7. Chandraratna PA, Mohar DS, Sidarous PF: Role of echocardiography in the treatment of cardiac tamponade. Echocardiography 2014;31:899–910. 8. Callahan JA, Seward JB: Pericardiocentesis guided by two-dimensional echocardiography. Echocardiography 1997;14:497–504.
Giant Purulent Pericarditis
9. Augustin P, Desmard M, Mordant P, et al: Clinical review: intrapericardial fibrinolysis in management of purulent pericarditis. Crit Care 2011;15:220. 10. Loukas M, Walters A, Boon JM, et al: Pericardiocentesis: a clinical anatomy review. Clin Anat 2012;25:872–881.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clips S1 and S2. Fig. 1C–E revealing huge pericardial effusion (most prominent in the
right ventricular site with more than 5 cm in diameter) surrounding the heart and compressing right atrium and ventricle in transthoracic echocardiography. Movie clips S3 and S4. Fig. 2C–E revealing salient residual pericardial effusion and marked thickening both in visceral and parietal pericardium in control echocardiography concordant with effusive constrictive pericarditis.
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Echocardiography
Giant Purulent Pericarditis with Cardiac Tamponade Due to Streptococcus intermedius Rapidly Progressing to Constriction Elif T. Tigen, M.D.,* Ibrahim Sari, M.D.,† Koray Ak, M.D.,‡ Sena Sert, M.D.,† Kursat Tigen, M.D.,† and Volkan Korten, M.D.* *Department of Infectious Diseases, School of Medicine, Marmara University, Istanbul, Turkey; †Department of Cardiology, School of Medicine, Marmara University, Istanbul, Turkey; and ‡Department of Cardiovascular Surgery, School of Medicine, Marmara University, Istanbul, Turkey
Purulent pericardial effusion, although rare, is a life-threatening condition usually produced by the extension of a nearby bacterial infection locus or by blood dissemination in the immune-suppressed subjects or in the course of cardiothoracic surgery. Because clinical features of purulent pericardial effusion are often nonspecific, it can cause delay in diagnosis. Therefore, a high index of suspicion is required for timely diagnosis and management. Herein, we describe a case of giant purulent pericardial effusion due to Streptococcus intermedius with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via parasternal approach, appropriate antibiotics, and pericardiectomy. (Echocardiography 2015;32:1318–1321) Key words: giant purulent pericarditis, pericardial effusion, tamponade, Streptococcus intermedius, constrictive pericarditis
Purulent pericarditis is characterized by purulent pericardial effusion, which is generally produced by the extension of a nearby bacterial infection locus or by blood dissemination.1 Generally clinical presentation is severe and tends to progress to cardiac tamponade and constriction. Herein, we describe a case of giant purulent pericardial effusion due to Streptococcus intermedius with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via parasternal approach, appropriate antibiotics, and pericardiectomy. Case Presentation: A 19-year-old man presented to our emergency department with worsening dyspnea, palpitation, nausea, and abdominal pain for the last several days. His medical history was remarkable for bronchiectasis (diagnosed 7 years ago) and several hospitalizations due to pneumonia (last one 25 days ago). Immediate physical examination revealed cold and sweaty extremities, marked jugular venous distention, diminished heart Address for correspondence and reprint requests: Ibrahim Sari, M.D., Professor in Cardiology, Department of Cardiology, School of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey. Fax: + 90-216-6570695; E-mail: [email protected]
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sounds, abdominal tenderness, and clubbing. Admission vital signs were as follows: blood pressure, 95/73 mm Hg; pulse rate, 139/min; respiratory rate, 26/min; temperature, 36.5 °C; and O2 saturation, 90% on room air. His electrocardiogram was unremarkable except sinus tachycardia. Laboratory values were as follows: hemoglobin level, 10.6 g/dL; white blood cell count, 7100/lL; platelet, 313.000/lL; C-reactive protein, 103 mg/L; aspartate amino transferase, 260 U/L; and alanine amino transferase, ALT:579 U/L. Chest x-ray showed bottle shape cardiomegaly and bilateral costophrenic sinuses were closed. Computed tomography of thorax revealed giant pericardial effusion surrounding all heart and almost obliterating right heart chambers with bilateral pleural effusion (Fig. 1A,B). Transthoracic echocardiography revealed huge pericardial effusion (most prominent in the right ventricular site with more than 5 cm in diameter) surrounding the heart and compressing right atrium and ventricle (Fig. 1C–E, movie clips S1 and S2). There were marked respiratory variations in mitral and tricuspid inflow patterns compatible with tamponade (Fig. 1F). In subcostal view, inferior vena cava was dilated (28 mm), and there was no respiratory variation in its diameter.
Giant Purulent Pericarditis
Because clinical scenario was compatible with tamponade, we performed echocardiography-guided pericardiocentesis via parasternal approach (Fig. 2A). In the first stage, 950 mL straw-colored purulent fluid was evacuated (Fig. 2B) and a pigtail drainage catheter was left in the pericardial cavity. Pericardial fluid glucose was 2 mg/dL, protein 5 mg/dL, LDH 120 U/L, triglyceride 30 mg/dL, and white blood cell count 4150/lL. Repeated pericardial fluid cultures were positive for S. intermedius. We started intravenous ampicillin/sulbactam four times a day. After a total of 2700 mL purulent fluid drainage in 72 hours, obstruction occurred in pigtail catheter (despite irrigation) and it was removed. Although we observed significant clinical and laboratory improvement with the help of pericardiocentesis and antibiotic therapy, control echocardiography revealed salient residual pericardial effusion and marked thickening both in visceral and in parietal pericardium (Fig. 2C–E, movie clips S3 and S4), which was concordant with effusive constrictive pericarditis. Surgical pericardiectomy was performed, which revealed very thick (more than 10 mm) pericardium (Fig. 2F) and resulted in complete relief of symptoms. Six months after the surgery, his control echocardiography was completely normal and he was free of any symptoms.
Discussion: Purulent pericardial effusion, although rare, is a life-threatening condition usually produced by the extension of a nearby bacterial infection locus or by blood dissemination in the immune-suppressed subjects or in the course of cardio-thoracic surgery.1 Because clinical features of purulent pericardial effusion are often nonspecific, it can cause delay in diagnosis. Therefore, a high index of suspicion is required for timely diagnosis and management. The most common cause of purulent pericardial effusion is Staphylococcus aureus and Streptococcus pneumoniae.2 To our knowledge, our case is the third patient in the literature who experiences purulent pericarditis due to S. intermedius.3,4 Streptococcus intermedius is a member of Streptococcus anginosus (milleri) group, which are normally found in normal flora of oral cavity and gastrointestinal tract; however, they can cause abscesses and systemic infections.5,6 In differential diagnosis, we considered chylous pericardial effusion; however, lack of trauma history, low level of triglyceride in pericardial fluid analysis, documentation of S. intermedius in consecutive pericardial fluid cultures, and history of bronchiectasis and repeated pneumonias made us to consider our case as purulent pericardial effusion. Treatment of purulent pericardial effusion consists of drainage of the pericardial fluid and
Figure 1. A,B. Thorax tomography demonstrating giant pericardial effusion surrounding the heart and almost obliterating right heart chambers with bilateral pleural effusion. C–E. Transthoracic echocardiography showing huge pericardial effusion (most prominent in the right ventricular site with more than 5 cm in diameter) surrounding the heart and compressing right atrium and ventricle. F. Marked respiratory variation in the mitral inflow pattern.
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Figure 2. A. Pericardiocentesis procedure via parasternal approach. B. Straw-colored purulent fluid. C–E. Considerable amount of residual pericardial effusion and marked thickening both in visceral and in parietal pericardium. F. Marked thickening of the pericardium (more than 10 mm) during surgical pericardiectomy.
culture-guided antibiotherapy.1,2,7,8 Despite pericardiocentesis and appropriate antibiotic treatment, constrictive pericarditis often complicates the scenario. Although some authors suggest prophylactic surgical pericardiectomy in all patients with purulent pericarditis, it is controversial.1 In our case, because constrictive physiology persisted after pericardiocentesis and appropriate antibiotherapy (considerable amount of residual pericardial effusion, thickened visceral and parietal pericardium, tachycardia, persistent septal bouncing in echocardiography), we performed pericardiectomy. Intrapericardial fibrinolysis and/or irrigation with saline or antibiotics to facilitate dissolution of inflammatory and infectious substances and enhance antibiotic penetration might also be used to minimize the risk of constrictive pericarditis; however, this approach needs more data.9 Generally pericardiocentesis is performed via subxiphoid approach. We performed parasternal pericardiocentesis because it is reported to be simple and more safe than subxiphoid approach.10 Additionally, we were concerned about possible dissemination of the infection to the abdominal cavity. In conclusion, the present paper reports a rare case of giant purulent pericardial effusion due to S. intermedius in a young male with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via paras1320
ternal approach, appropriate antibiotics, and pericardiectomy. References 1. Petcu CP, Dilof R, Bataıosu C, et al: Purulent pericardial effusions with pericardial tamponade – diagnosis and treatment issues. Curr Health Sci J 2013;39:53–56. 2. Maisch B, Seferovic PM, Ristic 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: 587–610. 3. Muto M, Ohtsu A, Boku N, et al: Streptococcus milleri infection and pericardial abscess associated with esophageal carcinoma: report of two cases. Hepatogastroenterology 1999;46:1782–1784. 4. Presnell L, Maeda K, Griffin M, et al: A child with purulent pericarditis and Streptococcus intermedius in the presence of a pericardial teratoma: an unusual presentation. J Thorac Cardiovasc Surg 2014;147:e23–e24. 5. Claridge JE 3rd, Attorri S, Musher DM, et al: Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (“Streptococcus milleri group”) are of different clinical importance and are not equally associated with abscess. Clin Infect Dis 2001; 32:1511–1515. 6. Whiley RA, Beighton D, Winstanley TG, et al: Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infections. J Clin Microbiol 1992;30:243–244. 7. Chandraratna PA, Mohar DS, Sidarous PF: Role of echocardiography in the treatment of cardiac tamponade. Echocardiography 2014;31:899–910. 8. Callahan JA, Seward JB: Pericardiocentesis guided by two-dimensional echocardiography. Echocardiography 1997;14:497–504.
Giant Purulent Pericarditis
9. Augustin P, Desmard M, Mordant P, et al: Clinical review: intrapericardial fibrinolysis in management of purulent pericarditis. Crit Care 2011;15:220. 10. Loukas M, Walters A, Boon JM, et al: Pericardiocentesis: a clinical anatomy review. Clin Anat 2012;25:872–881.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clips S1 and S2. Fig. 1C–E revealing huge pericardial effusion (most prominent in the
right ventricular site with more than 5 cm in diameter) surrounding the heart and compressing right atrium and ventricle in transthoracic echocardiography. Movie clips S3 and S4. Fig. 2C–E revealing salient residual pericardial effusion and marked thickening both in visceral and parietal pericardium in control echocardiography concordant with effusive constrictive pericarditis.
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