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A3525 - Purulent Pericarditis: A Case of Sinking Heart
Author Block: M. Shahid1, A. Verma2, S. Ghalib3, P. Koo4; 1Internal Medicine, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States, 2Internal Medicine, University of Tennessee College of Medicine, Chattanooga, TN, United States, 3University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States, 4University of Tennessee College of Medicine, Chattanooga, TN, United States.
Introduction: Purulent pericarditis is a rare entity in current practice. Historically it has been associated with immunocompromised status and occurs most commonly as a complication of untreated pneumonia/empyema, post thoracic surgery or in the setting of endocarditis. A large effusion can cause tamponade, leading to hemodynamic instability warranting an emergent pericardiocentesis. The mortality rate is 100% in the absence of proper management and more than half cases are diagnosed post mortem. Diagnosis requires demonstration of leucocytes in the pericardial effusion with or without the causative organism on gram stain. Here we describe a case of purulent pericarditis in a young immunocompetent patient.
Case Presentation: A 32 year old female with past medical history significant for intravenous drug abuse was transferred from an outside hospital for management of infective endocarditis. Patient’s initial symptoms consisted of malaise, subjective fevers, and chills. Her vital signs were as following: BP 80/45mmHg, HR 120 beats/min, respiratory rate 20/min, temperature 102 degrees Fahrenheit. Pertinent physical exam findings on admission showed a cachectic female with needle tracks on all limbs, muffled heart sounds, jugular venous distention, and diaphoresis. Laboratory data revealed leukocytosis (WBC count 16,000/mm3). Patient was started on broad spectrum antibiotics and crystalloid fluids. Her blood pressure improved minimally to 85/47mmHg after 2L of normal saline and, therefore, norepinephrine was started. EKG showed sinus tachycardia without electrical alternans. A transthoracic echocardiogram revealed a large pericardial effusion with tamponade physiology. She underwent an emergent pericardiocentesis, which yielded 450mL of purulent pericardial effusion. Patient’s hemodynamic status improved after the procedure. Blood cultures and pericardial fluid grew MRSA in less than 12 hours. Patient was treated with Vacomycin and after a prolonged hospital course she was discharged to a rehabilitation facility.
Discussion: The incidence of purulent pericarditis has dropped significantly in the antibiotic era with the most recent data showing an incidence rate of 1 in 18,000 (versus 1 in 254 in pre antibiotic era). Early recognition and intervention are crucial to stabilize the patient. Classic auscultation signs of pericarditis (pericardial knock/rub) are usually absent in purulent pericarditis making diagnosis challenging. Treatment involves antibiotics with pericardiocentesis. The patient described above was immunocompetent (negative HIV status) and her clinical picture mimicked septic shock, masking the underlying pathology. This case scenario underlines the importance of early diagnosis and management of purulent pericardial effusion.