Purulent Pericardial effusion in Retro Virus infection

08 FEB 2013

 

PURULENT PERICARDIAL EFFUSION

 Alex A -PGY 1

 Fabith MoideenDeputy- Chief  ,  Ramanidharan- Faculty,  Harshad- PGY2

Venugopalan .P.P Chief

 

38 yr old male, was brought in to the Emergency Department with complaints of

retrosternal chest pain since 15 days.

General Impression: Conscious, oriented.

Primary survey:

Airway – patent, no obstruction

Breathing – air entry B/L equal, no added sounds.

Circulation-CRT-< 2 sec, peripheral pulses equal and felt.

Disability –alert, conscious, moving all limbs.

Exposure –.Bilateral pitting pedal edema, redness over foot bilaterally

Vitals:

BP-110/70 PR-124 SPO2-98 on room air, TEMP-afebrile RR- 18 GRBS-147

PAIN SCORE-3/10

Signs and symptoms-H/o - Retrosternal chest pain which Increase on coughing , deep

inspiration and leaning forward since 15 days . Constant pain .

No dyspnea .No radiation to neck , arms , back .

H/o fever, cough, loose stools for 4 days. , Fever mild to moderate grade not associated

with chills and rigors. h/o odynophagia +

Also gives h/o significant Wt loss . Decreased appetite . Fatigue +

Pedal edema + 1 day, redness over foot bilaterally

oral antibiotics .

Past Medical /Surgical History-

chronic smoker and chronic alcoholic

No other significant history

Last Meal: lunch, 3 pm

Events:in Nigeria, as an x ray welder, irregular meal timings, long fasting hours

between meals, skips dinner and has two meals per day. He received treatment from a

local general practitioner after which he found no relief, hence he came here to MIMS for

further management.

Head to Toeexamination

HEENT- normal

Trachea – central

JVD- normal

Chest – b/l air entry equal , no added sounds.

PA- soft, lax , BS +

CNS- conscious, alert, HMF – normal. Moving all limbs.

CVS- S1S2 ++, no murmurs.

INTIAL MANAGEMENT:

IV access

O2 – 4 lit with face mask

MONITOR: normal sinus rhythm.

Vitals rechecked,

Blood samples collected

Drugs administered :

• Inj pantocid 40 mg iv

• Tab ecospirin 300 mg p/o

• Tab clavix 300 mg p/o

Point of Care Ultrasound :

Pericardial effusion+.

Moderate LV dysfunction

No pneumothorax.

IVC: Normal

ECG-Sinus tachycardia , ST elevation in all leads except avR & V1

( Convex - upwards ST elevation ) ,PR – Normal.

D/D:

Pericarditis

Acute coronary syndrome

Lower Respiratory Tract Infection

Cardiac tamponade

Aortic dissection

Acute gastritis/Duodenal ulcer.

Oesophageal rupture

Oesophagitis

Pneumothorax

Pulmonary embolism

Costochondritis

Initial diagnosis:

Pyrexia of Unknown Origin

Possible Myocarditis / Pericarditis

INVESTIGATIONS

GRBS: 138 mg/dL

HIV 1 & 2[Card & ELISA]: POSITIVE / HBsAg [Card]: Negative / HCV [Card]: Negative /

VDRL: Negative

Peripheral smear: 1. Mild normocytic normochromic anemia. 2. Neutrophilic

leukocytosis

Pericardial fluid cytology: No malignant cells seen

Pericardial fluid culture: Staphylococcus aureus

Pericardial fluid Gram-Stain: Few Gram positive coccoid forms noted

 

Chest X-ray

Cardiac enlargement +

 

ECG -Sinus tachycardia, ST elevation in all leads except aVR and V1

ECHO

[on admission]: No RWMA. Valves normal

Normal biventricular function. LVEF = 55-60 %

No clots. Pericardial effusion + (2 cm in any direction)

No intra-cardiac clots. IVC dilated. Respiratory movements present

[pre-discharge]: Mild-to-moderate pericardial effusion with strands

No RA / RV collapse. No RWMA. Normal LV & RV function. LVEF - 55-60 %

Normal valves. Trivial mitral regurgitation

 

CT Thorax:

Moderate pericardial effusion. Small left pleural effusion

COURSE IN THE HOSPITAL

This gentleman, admitted with atypical chest pain and fever, was found to have large

pericardial effusion on echocardiogram and was hence admitted for further evaluation

and management. Blood investigations showed leukocytosis, neutrophilia and high

ESR. He was also found to be positive for retroviral antibodies. He was taken up for

pericardiocentesis and drained purulent pericardial fluid. Pericardial fluid culture grew

Staphylococcus aureus and antibiotics were started according to sensitivity. He was

afebrile since 12-01-2013. However, a repeat echo done showed re-accumulation of

pericardial fluid and underwent pericardiocentesis two further times during subsequent

hospital stay. A spiral CT scan thorax done did not show any evidence of mediastinal

lymphadenopathy / mass lesion. He was started on anti-retroviral therapy in consultation

with our Microbiologist. His Cryptococcal antigen test, PCR for TB, toxoplasma IgG

results are awaited. VDRL test was non-reactive. HIV viral load testing and CD4 + count

testing were also done – reports are awaited. He is advised to continue treatment from

local hospital. Antibiotics should be continued for 1 more week. I.V Gentamicin was

stopped after completing 15 days of therapy. At the time of discharge, he continued to

have moderate-to-large pericardial effusion with evidence of systemic venous congestion.

He is likely to require surgical intervention for pericardial effusion.

FINAL DIAGNOSIS:

LARGE PURULENT PERICARDIAL EFFUSION

SECONDARY DIAGNOSIS

RETROVIRAL POSITIVE STATE

Discussion

Purulent pericardial effusion :

Purulent(or suppurative) pericarditis is defined as an infection of

the pericardial space that produces pus Bacterial infections of the

pericardium are relatively uncommon but are much more likely to produce

purulent effusions and to proceed to cardiac tamponade and pericardial

constriction.

Purulent pericarditis occurs almost exclusively as a secondary infection in

patients with serious underlying disease, including patients with AIDS and

those undergoing hemodialysis, thoracic surgery, and chemotherapy.

Bacterial pericarditis has a high mortality rate despite appropriate therapy

(30%–50%), with the majority of deaths due to cardiac tamponade.

The reported incidence of pericardial involvement among patients with

pulmonary tuberculosis ranges from 1% to 8%; however, evidence of

active pulmonary disease is uncommon, with only 11% to 50% of patients

with tuberculous pericarditis having positive sputum cultures.

• Pericardial involvement can occur with a primary infection, reactivation of

latent infection, and during appropriate antitubercular therapy.

• The most common pathway is retrograde extension via lymphatics from

peribronchial and mediastinal nodes; other recognized pathways include

hematogenous spread from a distant foci (genitourinary or skeletal) and

direct extension from a contiguous source (lymph nodes, lung, pleura,

spine).

• Four pathologic stages of tuberculous pericarditis

have been identified:

(1) fibrin deposition with many polymorphonuclear neutrophils and

abundant

organisms as well as loose granuloma formation;

(2) accumulation of serosanguinous effusion with predominating

lymphocytes

and monocytes;

(3) absorption of the effusion, with a reduction in the number of

Mycobacterium

tuberculosis organisms and thickening of the pericardium due to the

formation

of dense caseating granulomas;

(4) replacement of granulomas by fibrous tissue, which begins to

Calcification may occur at any pathologic stage.

HIV Infection

• An estimated 6% to 7% of patients with HIV infection experience

significant HIV-related cardiac morbidity, and pericardial effusion and

myocarditis are the most common.

• Approximately 25% of HIV patients with advanced disease have an

effusion by echocardiography, and 20% of these effusions were large.

• The majority of patients were asymptomatic, and at follow-up 42% of the

effusions had resolved spontaneously.

• In a series of patients requiring intervention for tamponade, the most

common underlying disorders were malignancy and HIV.

• Pericardial disease can result from opportunistic infections, medical

treatment of HIV infection, and the HIV infection itself. In these

immunocompromised patients, one must consider not only viral and

bacterial pathogens, but also fungal, mycobacterial, and parasitic

(Toxoplasma gondii) infections.

• Noninfectious causes include lymphoma and Kaposi sarcoma.

• The risk factors associated with moderate-severe pericardial effusion

in patients with HIV infection were tuberculosis heart failure other

pulmonary infection , and Kaposi sarcoma.

• Thus, it is prudent to initiate empirical treatment for tuberculosis in a

patient with HIV who is symptomatic with a persistent pericardial effusion

until that diagnosis can be confirmed or excluded.

Lessons Learnt :

Purulent pericarditis is nearly always a complication of another infection,

and a high level of suspicion is needed to make the diagnosis.

In treating suspected bacterial pericarditis, broadspectrum antibiotics with

anaerobic coverage should be used until the microbe is identified.

Tachycardia is a sensitive but nonspecific sign of pericardial disease that

may signal early tamponade physiology

Hypotensive patients should be checked for pulsus paradoxus (especially

if they have jugular venous distention); if present, an echocardiogram

should be obtained.

A multidisciplinary approach including infectious disease,

cardiology,pulmonology and cardiothoracic surgery is optimal for making

the diagnosis of and providing the treatment for complex pericardial

infections.

References:

1) Rosen’s Textbook of Emergency Medicine (7th Edition)

2) Tintinally’s textbook of Emergency Medicine (7th Edition)

3) Harrison’s Principles of Internal Medicine – 4th Edition

4) Online references (Uptodate- Purulent pericardial effusion, ACEP Journal )