SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Bacterial pericarditis, a rare entity in the modern antibiotic era, has high mortality rates. We describe a case of purulent pericarditis and tamponade caused by Methicillin-Resistant Staphylococcus aureus (MRSA) secondary to MRSA urosepsis.
CASE PRESENTATION: A 67-year-old male was brought to the Emergency Department after being found unresponsive. He was hypothermic and hypotensive. Laboratory testing revealed a leukocyte count of 29400 cells/µL and 27% bands. Patient was resuscitated and started on empiric antibiotics. Blood and urine cultures grew MRSA sensitive to vancomycin. On day 12, patient became hypotensive with systolic blood pressure ranging from 70-80 mm of Hg. He had a jugular venous pressure (JVP) of 12 cm and muffled heart sounds. ECG showed low voltages in precordial leads. An emergent echocardiogram revealed impending tamponade due to a 4.6 cm circumferential fluid accumulation in the pericardium. This was absent in a study done 5 days prior. A computerized tomography (CT) scan of the chest showed a large pericardial effusion (Fig. 1 & 2). Pericardiocentesis yielded 800 cc of purulent fluid which grew MRSA. His condition improved and a subsequent echocardiogram showed residual fibrinous pericardial stranding.
DISCUSSION: Bacterial pericarditis is associated with mortality rates reaching 40% despite treatment. Staphylococcus aureus and Streptococcus pneumoniae are the commonest causative pathogens, but gram-negative and anerobic organisms are gaining prevalence. Primary infection of the pericardium is rare. It typically occurs as a result of hematogenous spread, direct trauma or local extension of a suppurative focus in the lung, myocardium or sub-diaphragmatic source. Patients typically present with high fevers, chills and tachycardia. Predisposing factors include underlying infection, recent thoracic surgery, immunosuppression, alcohol abuse, malignancy and rarely acute myocardial infarction. Prompt surgical drainage and appropriate antibiotic therapy is the treatment of choice. Subsequent placement of an indwelling pericardial catheter is useful for cardiac tamponade. Pericardiectomy can be done if percutaneous drainage is insufficient or ineffective. Major long-term complications are recurrence and constrictive pericarditis.
CONCLUSIONS: Bacterial pericarditis is uncommon but potentially life-threatening. Surviving this catastrophic illness requires a high index of suspicion, early diagnosis, prompt pericardial drainage and appropriate antibiotic therapy.
1) Parikh SV, Memon N, Eschols M: Purulent pericarditis: report of 2 cases and review of literature: Medicine. 2009;88:52-65
2) Klacsmann PG, Bulkley BH, Hutchins GM: The changed spectrum of purulent pericarditis: an 86-year autopsy experience in 200 patients: Am J Med. 1977;63:666-673
3) Rubin RH, Moellering RC Jr: Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med. 1975;59:68-78
DISCLOSURE: The following authors have nothing to disclose: Shine Raju, Anupam Kumar, Ranjit Joseph, Bimalin Lahiri
No Product/Research Disclosure InformationUConn Health Center, Farmington, CT