PURULENT PERICARDIAL EFFUSION Alex A -PGY 1 Fabith MoideenDeputy- Chief, Ramanidharan- Faculty, Harshad- PGY2 Venugopalan.P.

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1 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 Historychronic 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 Toe examination 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

2 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

3 ECHO [on admission]: No RWMA. Valves normal Normal biventricular function. LVEF = % 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 % Normal valves. Trivial mitral regurgitation

4 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 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

5 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.

6 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 )