(176) A Vicious Decline: A Case of Cardiac Tamponade Secondary to Purulent Pericarditis

Introduction: Purulent pericarditis is a rare presentation of infection localized to the pericardial space. A retrospective review of a hospitalized population found only 33 cases from 593,600 patients, and of those 33 cases, 14 were a postmortem diagnosis. In cases of purulent pericarditis, the incidence of cardiac tamponade ranges from 42 to 77%. In patients with intrathoracic infections, Streptococcus pneumoniae is the most frequently isolated organism. Since advancements in medicine and antibiotic therapies, there has been a decline in the number of cases observed in recent decades.

Description: The patient is a 51-year-old female with PMH of Crohn's disease who presented with chief complaint of shortness of breath and fevers, admitted to the ICU due to sepsis from a left sided empyema found on CT. A thoracostomy was performed and was empirically treated with cefepime with improvement. A TTE was obtained, which showed large pericardial effusion with no evidence of tamponade. Her pleural fluid cultures grew S. Pneumoniae, and antibiotics were tailored to ceftriaxone. She was subsequently downgraded from the ICU to PCU. The following day she had a PEA arrest and ROSC was obtained, however she remained in profound shock, requiring multiple fluid boluses and pressors. She was brought back to ICU and a STAT echo was obtained which did not show tamponade features, however, clinical suspicion for tamponade remained high. A bedside pericardiocentesis was performed which drained approximately 700 ml of purulent material. Immediately after, her pressor requirements drastically dropped, and she was treated with empiric Vancomycin and ceftriaxone. Her pericardial fluid showed predominant WBCs, but no organisms, likely sterile due to empiric antibiotics. S. Pneumoniae was suspected, as it had been seen isolated in the pleural studies. She was ultimately discharged from the hospital.

Discussion: This was a rare presentation of a cardiac tamponade, and the fact that she survived her hospital stay is even less commonly reported.
In patients with intrathoracic infections and pericardial effusion, purulent pericarditis should be considered in the differential. A rapid diagnosis can mean the difference between life and death, as it can lead to cardiac tamponade and cardiac arrest.