BRIEF CLINICAL OBSERVATIONS
PURULENTTUBERCULOUSPERICARDITISWITH CARDIACTAMPONADE Tuberculous pericarditis usually presentsas an insidiousprogressivedisease.This chronicpericardial inflammation can lead to hemodynamic consequences,which may appearas the sole symptoms [l]. Pericardial fluid is commonly watery or serosanguineous,containing mostly lymphocytes. We report here a different aspect. An 89-year-oldwoman was admitted to the hospital becauseof an impaired health state with fever. Her only antecedentcondition was diabetesmellitus treated by glibenclamide. She was well until 8 daysbeforeadmission,when sheexperiencedasthenia, cough,and mild fever. On admission,shehad a temperature of 38OC,blood pressureof 130/90mm Hg, heart rate of 120 beats/mm, and respiratory rate of 28/min; neither signs of cardiac failure nor pulsusparadoxuswaspresent.Neurologicexamination revealedonly obtundation; the neck was supple. A chestradiographdisclosedan enlargedcardiac sizeand normal lung parenchymawithout calcification. The result of a lumbar puncture was normal. An electrocardiogramdemonstratedsinus tachycardia and rare supraventricular extrasystoles. Hypotension progressivelydevelopedassociated with distended jugular veins, enlargementof the cardiac silhouette on radiography, and microvoltage on electrocardiogram;central venouspressure was 35 cm H20. Echocardiographyshoweda pericardial effusion compressing the right heart cavities. Surgical pericardial drainage yielded 500 mL of a purulent fluid containing a protein level of 35 g/L and a nucleated cell count of 13,500/mm3 (76%polymorphonuclear leukocytes);microscopic examination revealed numerous acid-fast bacilli (greater than lOO/smear)without other microorganisms.Cultures were positive only for Mycobacterium tuberculosis (aswerecultures of urine samples and bronchial secretions).Histologic examination of a pericardial biopsy specimen disclosed fibrinopurulent pericarditis without granuloma or malignant tumor cells. Ziehl staining was strongly positive. Treatment consisted of rifampin (600 mg/d), isoniaxid (300mg/d) , and ethambutol(l,200 mg/d). Progressivecardiac failure without recurrence of tamponade was unresponsiveto mechanical ventilation associatedwith intravenousinfusion of dobutamine and epinephrine. The patient died 10 days after admission. In the absenceof pneumonia, tuberculous pericarditis can occur during pericardial metastatic localization of miliary tuberculosis,rupture of a mediastinal lymph node with extensioninto the peri-
cardium, or reactivation from a pleural or rib disease[2]. Acid-fast bacilli are rarely seen(or seen in a small number) on microscopic examination of the pericardial fluid. Although it is admitted that, on rare occasions,tuberculosiscan presentasacute purulent pericarditis, and that the presenceof polymorphonuclear leukocytes is the initial histologic responseto the acuteinfection [l], reports of such a presentationare rare or questionable[3]. So,tuberculosis is not usually part of the diagnosisof purulent pericarditis. The presenceof polymorphonuclearleukocytesassociatedwith numerousacid-fast bacilli in the pericardial fluid and a positive culture of pericardial fluid for M. tuberculosis indicates that the pericarditis is dueto tuberculosis,and confirms that tuberculosis must be consideredin the differential diagnosisof acutepurulent pericarditis. IS~ELLE DELACROIX,M.D. FRANK THOMAS,M.D. JEAN GODART,M.D. YVESRAVAUD, M.D. Hapita des Diaconesses Paris, France 1. Locks MO. Tuberculous and fungal pericarditis. West J Med 1975; 122: 300-5. 2. Harris LF. Tuberculous pericarditis, a unique experience. Ala Med 1987; 57: 16-23. 3. Carli P. Formes purulentes de shrites tuberculeuses. Med Trop (Mars) 1989; 49: 193-6. Submitted
August 23, 1991, and accepted
in revised form November
8. 1991
GAS-FORMINGSOFT TISSUEABSCESSCAUSED BY STREPTocoCCUSPiVEiJMOIVlAE Streptococcus pneumoniae hasnot beenassociated with gas in the soft tissues [l-5]. This casereport illustrates that a gas-formingsoft tissue abscessis a possible manifestation of disseminated S. pneumoniae infection. Case Report. A &year-old homosexual man with no history of intravenousdrug use,connective tissue disease,previous infection with an encapsulated organism,or recentcorticosteroidtherapy was in goodhealth until he developeda nonproductive cough and sharp intermittent left anterior chest pain. Two days later, the patient beganto experienceswelling of his right lower leg. During the succeeding 5 days, this swelling progressedand the patient was hospitalized. Physical examination showeda temperatureof 39”C, a left infraclavicular fullness, decreasedbreath sounds upon anterior auscultation of the left upper lung field, and a right knee effusion as well as an erythematous,edematous, and tender right lower leg. No heart murmur
July 1992 The American Journal of Medicine
Volume 93
105
PURULENTTUBERCULOUSPERICARDITISWITH CARDIACTAMPONADE Tuberculous pericarditis usually presentsas an insidiousprogressivedisease.This chronicpericardial inflammation can lead to hemodynamic consequences,which may appearas the sole symptoms [l]. Pericardial fluid is commonly watery or serosanguineous,containing mostly lymphocytes. We report here a different aspect. An 89-year-oldwoman was admitted to the hospital becauseof an impaired health state with fever. Her only antecedentcondition was diabetesmellitus treated by glibenclamide. She was well until 8 daysbeforeadmission,when sheexperiencedasthenia, cough,and mild fever. On admission,shehad a temperature of 38OC,blood pressureof 130/90mm Hg, heart rate of 120 beats/mm, and respiratory rate of 28/min; neither signs of cardiac failure nor pulsusparadoxuswaspresent.Neurologicexamination revealedonly obtundation; the neck was supple. A chestradiographdisclosedan enlargedcardiac sizeand normal lung parenchymawithout calcification. The result of a lumbar puncture was normal. An electrocardiogramdemonstratedsinus tachycardia and rare supraventricular extrasystoles. Hypotension progressivelydevelopedassociated with distended jugular veins, enlargementof the cardiac silhouette on radiography, and microvoltage on electrocardiogram;central venouspressure was 35 cm H20. Echocardiographyshoweda pericardial effusion compressing the right heart cavities. Surgical pericardial drainage yielded 500 mL of a purulent fluid containing a protein level of 35 g/L and a nucleated cell count of 13,500/mm3 (76%polymorphonuclear leukocytes);microscopic examination revealed numerous acid-fast bacilli (greater than lOO/smear)without other microorganisms.Cultures were positive only for Mycobacterium tuberculosis (aswerecultures of urine samples and bronchial secretions).Histologic examination of a pericardial biopsy specimen disclosed fibrinopurulent pericarditis without granuloma or malignant tumor cells. Ziehl staining was strongly positive. Treatment consisted of rifampin (600 mg/d), isoniaxid (300mg/d) , and ethambutol(l,200 mg/d). Progressivecardiac failure without recurrence of tamponade was unresponsiveto mechanical ventilation associatedwith intravenousinfusion of dobutamine and epinephrine. The patient died 10 days after admission. In the absenceof pneumonia, tuberculous pericarditis can occur during pericardial metastatic localization of miliary tuberculosis,rupture of a mediastinal lymph node with extensioninto the peri-
cardium, or reactivation from a pleural or rib disease[2]. Acid-fast bacilli are rarely seen(or seen in a small number) on microscopic examination of the pericardial fluid. Although it is admitted that, on rare occasions,tuberculosiscan presentasacute purulent pericarditis, and that the presenceof polymorphonuclear leukocytes is the initial histologic responseto the acuteinfection [l], reports of such a presentationare rare or questionable[3]. So,tuberculosis is not usually part of the diagnosisof purulent pericarditis. The presenceof polymorphonuclearleukocytesassociatedwith numerousacid-fast bacilli in the pericardial fluid and a positive culture of pericardial fluid for M. tuberculosis indicates that the pericarditis is dueto tuberculosis,and confirms that tuberculosis must be consideredin the differential diagnosisof acutepurulent pericarditis. IS~ELLE DELACROIX,M.D. FRANK THOMAS,M.D. JEAN GODART,M.D. YVESRAVAUD, M.D. Hapita des Diaconesses Paris, France 1. Locks MO. Tuberculous and fungal pericarditis. West J Med 1975; 122: 300-5. 2. Harris LF. Tuberculous pericarditis, a unique experience. Ala Med 1987; 57: 16-23. 3. Carli P. Formes purulentes de shrites tuberculeuses. Med Trop (Mars) 1989; 49: 193-6. Submitted
August 23, 1991, and accepted
in revised form November
8. 1991
GAS-FORMINGSOFT TISSUEABSCESSCAUSED BY STREPTocoCCUSPiVEiJMOIVlAE Streptococcus pneumoniae hasnot beenassociated with gas in the soft tissues [l-5]. This casereport illustrates that a gas-formingsoft tissue abscessis a possible manifestation of disseminated S. pneumoniae infection. Case Report. A &year-old homosexual man with no history of intravenousdrug use,connective tissue disease,previous infection with an encapsulated organism,or recentcorticosteroidtherapy was in goodhealth until he developeda nonproductive cough and sharp intermittent left anterior chest pain. Two days later, the patient beganto experienceswelling of his right lower leg. During the succeeding 5 days, this swelling progressedand the patient was hospitalized. Physical examination showeda temperatureof 39”C, a left infraclavicular fullness, decreasedbreath sounds upon anterior auscultation of the left upper lung field, and a right knee effusion as well as an erythematous,edematous, and tender right lower leg. No heart murmur
July 1992 The American Journal of Medicine
Volume 93
105
