Purulent pericarditis

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Purulent Pericarditis
Pericardial effusion with tamponade.gif
Echocardiogram showing pericardial effusion with signs of cardiac tamponade
Specialty Cardiology
Symptoms substernal chest pain (exacerbated supine and with breathing deeply), dyspnea, fever, rigors/chills, and cardiorespiratory signs (i.e., tachycardia, friction rub, pulsus paradoxus, pericardial effusion, cardiac tamponade, pleural effusion)
Usual onsetacute
Causesrecent surgery, adjacent infection, trauma, primary infection
Diagnostic method electrocardiogram (ECG), echocardiogram/cardiac ultrasound ("echo"), chest radiograph, clinical symptoms, laboratory tests
Treatmentantibiotics, pericardiocentesis, pericardiectomy, pericardial window, video-assisted thoracic surgery

Purulent pericarditis refers to localized inflammation in the setting of infection of the pericardial sac surrounding the heart. [1] In contrast to other causes of pericarditis which may have a viral etiology, purulent pericarditis refers specifically to bacterial or fungal infection of the pericardial sac. [2] Clinical etiologies of purulent pericarditis may include recent surgery, adjacent infection, trauma, or even primary infection. [3] The onset of purulent pericarditis is usually acute, with most individuals presenting to a medical facility approximately 3 days following the onset of symptoms. [4]

Contents

As a subtype of pericarditis, purulent pericarditis often presents with substernal chest pain that is exacerbated by deep breathing and lying in the supine position. [5] Other presenting features that may be more specific for purulent pericarditis include fever, rigors/chills, and cardiorespiratory signs (i.e., tachycardia, friction rub, pulsus paradoxus, pericardial effusion, cardiac tamponade, pleural effusion). [4] The incidence of cardiac tamponade varies from 42-77% and is associated with rapid-onset mortality, especially without prompt intervention. [4]

Chest radiography may reveal cardiomegaly, pneumonia, pleural effusion, and/or mediastinal widening. [4] Electrocardiogram (ECG) is a component of the diagnostic work-up which may suggest pericarditis as the underlying cause of symptoms. The ECG findings for purulent pericarditis are similar to those for other etiologies of pericarditis. ECG findings may include diffuse S-T segment elevation, diffuse T wave inversion, low QRS voltage, and/or electrical alternans. [4] [6] Echocardiogram may be used to evaluate for fluid collection in the pericardial sac, and may be important in guiding therapy in patients with signs of cardiac compromise (i.e., cardiac tamponade). [3] [7]

Treatment modalities for purulent pericarditis include antibiotic therapy, with potential adjuncts such as pericardiocentesis or pericardial window when cardiac compromise is evident. [3]

Causes

Purulent pericarditis is usually caused by bacterial or fungal infection of the pericardial sac surrounding the heart. [2] In modern medicine, the incidence of purulent pericarditis is uncommon. One study conducted in Spain identified an incidence < 0.006 in a population of 593,600. [8] When comparing the pre-antibiotic period with the modern era of medicine, there is increased difficulty identifying a primary source of infection in the modern era of medicine. [9] Primary infectious disease in the pre-antibiotic era was found most commonly secondary to pneumonia or endocarditis, whereas pneumonia or meningitis have been found more commonly in the modern era. Other risk factors that contribute to the development of purulent pericarditis include recent thoracic surgery, chronic renal failure, malignancy, immunosuppression, alcohol abuse, thoracic surgery, and chest trauma. [3]

Signs and symptoms

Purulent pericarditis usually presents acutely, marked by high fever, tachycardia, cough, and chest pain. [3] While fever is present in almost all presentations, chest pain is less common when comparing purulent pericarditis to acute pericarditis from other etiologies. [4] [8] Additionally, a pericardial friction rub is present in 35-45% of cases, and the incidence of cardiac tamponade ranges from 42 to 77%. [4] [8] Studies have indicated that the average time elapsed before hospitalization is 3–10 days. [4] [8]

Diagnosis

Image of an ECG consistent with pericarditis. PericarditisECG.JPG
Image of an ECG consistent with pericarditis.
Image showing chest x-ray (CXR) consistent with cardiomegaly. Cardiomegally.PNG
Image showing chest x-ray (CXR) consistent with cardiomegaly.

The diagnosis of purulent pericarditis requires a combination of clinical assessment, laboratory tests, and imaging studies. Pericardiocentesis with evaluation of pericardial fluid by culture and microscopy is necessary to make the diagnosis, however several other findings may increase the likelihood of purulent pericarditis. [3]

Treatment

Image depicting pericardiocentesis. Pericardiocentesis.jpg
Image depicting pericardiocentesis.

Treatment for purulent pericarditis consists of two main components. [3]

  1. Antimicrobial therapy. Empiric intravenous antimicrobial therapy is recommended as soon as a diagnosis of purulent pericarditis is suspected. [3]
  2. Pericardial drainage. There are several therapeutic mechanisms that can be used to drain purulent fluid from the pericardial sac. These include pericardiocentesis, and possible subxiphoid pericardiotomy, pericardiectomy, and video-assisted thoracic surgery in complicated cases. [3] [8] [10]

See also

Related Research Articles

<span class="mw-page-title-main">Pericardium</span> Double-walled sac containing the heart and roots of the great vessels

The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue, and an inner layer made of serous membrane. It encloses the pericardial cavity, which contains pericardial fluid, and defines the middle mediastinum. It separates the heart from interference of other structures, protects it against infection and blunt trauma, and lubricates the heart's movements.

<span class="mw-page-title-main">Cardiac tamponade</span> Buildup of fluid around the heart

Cardiac tamponade, also known as pericardial tamponade, is a compression of the heart due to pericardial effusion. Onset may be rapid or gradual. Symptoms typically include those of obstructive shock including shortness of breath, weakness, lightheadedness, and cough. Other symptoms may relate to the underlying cause.

<span class="mw-page-title-main">Constrictive pericarditis</span> Medical condition

Constrictive pericarditis is a condition characterized by a thickened, fibrotic pericardium, limiting the heart's ability to function normally. In many cases, the condition continues to be difficult to diagnose and therefore benefits from a good understanding of the underlying cause.

<span class="mw-page-title-main">Pericarditis</span> Medical condition

Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sitting up and more severe when lying down or breathing deeply. Other symptoms of pericarditis can include fever, weakness, palpitations, and shortness of breath. The onset of symptoms can occasionally be gradual rather than sudden.

<span class="mw-page-title-main">Pericardiocentesis</span> Procedure where fluid is aspirated from the pericardium

Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium.

Dressler syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium. It consists of fever, pleuritic pain, pericarditis and/or pericardial effusion.

<span class="mw-page-title-main">Esophageal rupture</span> Medical condition

Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery. In contrast, the term Boerhaave syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. Pulsus paradoxus is not related to pulse rate or heart rate, and it is not a paradoxical rise in systolic pressure. Normally, blood pressure drops less precipitously than 10 mmHg during inhalation. Pulsus paradoxus is a sign that is indicative of several conditions most commonly pericardial effusion.

<span class="mw-page-title-main">Pericardial effusion</span> Medical condition

A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of the serous membrane enclose the pericardial cavity between them. This pericardial space contains a small amount of pericardial fluid, normally 15-50 mL in volume. The pericardium, specifically the pericardial fluid provides lubrication, maintains the anatomic position of the heart in the chest, and also serves as a barrier to protect the heart from infection and inflammation in adjacent tissues and organs.

<span class="mw-page-title-main">Pericardial fluid</span>

Pericardial fluid is the serous fluid secreted by the serous layer of the pericardium into the pericardial cavity. The pericardium consists of two layers, an outer fibrous layer and the inner serous layer. This serous layer has two membranes which enclose the pericardial cavity into which is secreted the pericardial fluid. The fluid is similar to the cerebrospinal fluid of the brain which also serves to cushion and allow some movement of the organ.

<span class="mw-page-title-main">Acute pericarditis</span> Medical condition

Acute pericarditis is a type of pericarditis usually lasting less than 6 weeks. It is the most common condition affecting the pericardium.

<span class="mw-page-title-main">Electrical alternans</span> Medical condition

Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats and a possible wandering base-line. It is seen in cardiac tamponade and severe pericardial effusion and is thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium, as the heart essentially wobbles in the fluid filled pericardial sac.

Pericardiectomy is the surgical removal of part or most of the pericardium. This operation is most commonly used to relieve constrictive pericarditis, or to remove a pericardium that is calcified and fibrous. It may also be used for severe or recurrent cases of pericardial effusion. Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat.

<span class="mw-page-title-main">Myocardial rupture</span> Medical condition

Myocardial rupture is a laceration of the ventricles or atria of the heart, of the interatrial or interventricular septum, or of the papillary muscles. It is most commonly seen as a serious sequela of an acute myocardial infarction.

Autoimmune heart diseases are the effects of the body's own immune defense system mistaking cardiac antigens as foreign and attacking them leading to inflammation of the heart as a whole, or in parts. The commonest form of autoimmune heart disease is rheumatic heart disease or rheumatic fever.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

<span class="mw-page-title-main">Hemopericardium</span> Medical condition

Hemopericardium refers to blood in the pericardial sac of the heart. It is clinically similar to a pericardial effusion, and, depending on the volume and rapidity with which it develops, may cause cardiac tamponade.

A pericardial window is a cardiac surgical procedure to create a fistula – or "window" – from the pericardial space to the pleural cavity. The purpose of the window is to allow a pericardial effusion or cardiac tamponade to drain from the space surrounding the heart into the chest cavity.

<span class="mw-page-title-main">Postpericardiotomy syndrome</span> Medical condition

Postpericardiotomy syndrome (PPS) is a medical syndrome referring to an immune phenomenon that occurs days to months after surgical incision of the pericardium. PPS can also be caused after a trauma, a puncture of the cardiac or pleural structures, after percutaneous coronary intervention, or due to pacemaker or pacemaker wire placement.

<span class="mw-page-title-main">Chest pain in children</span> Medical condition

Chest pain in children is the pain felt in the chest by infants, children and adolescents. In most cases the pain is not associated with the heart. It is primarily identified by the observance or report of pain by the infant, child or adolescent by reports of distress by parents or caregivers. Chest pain is not uncommon in children. Many children are seen in ambulatory clinics, emergency departments and hospitals and cardiology clinics. Most often there is a benign cause for the pain for most children. Some have conditions that are serious and possibly life-threatening. Chest pain in pediatric patients requires careful physical examination and a detailed history that would indicate the possibility of a serious cause. Studies of pediatric chest pain are sparse. It has been difficult to create evidence-based guidelines for evaluation.

References

  1. ↑ Costa, Laura; Carvalho, Diana; Coelho, Elisabete; Leal, Dina; Lencastre, Luís (2021-07-14). "Purulent Pericarditis: Is It Really a Disease of the Past?". European Journal of Case Reports in Internal Medicine. 8 (7): 002658. doi:10.12890/2021_002658. ISSN   2284-2594. PMC   8336749 . PMID   34377691.
  2. 1 2 Tingle, Leslie E.; Molina, Daniel; Calvert, Charles W. (2007-11-15). "Acute pericarditis". American Family Physician. 76 (10): 1509–1514. ISSN   0002-838X. PMID   18052017.
  3. 1 2 3 4 5 6 7 8 9 Adler, Yehuda; Charron, Philippe; Imazio, Massimo; Badano, Luigi; Barón-Esquivias, Gonzalo; Bogaert, Jan; Brucato, Antonio; Gueret, Pascal; Klingel, Karin; Lionis, Christos; Maisch, Bernhard; Mayosi, Bongani; Pavie, Alain; Ristić, Arsen D; Sabaté Tenas, Manel (2015-11-07). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN   0195-668X. PMC   7539677 . PMID   26320112.
  4. 1 2 3 4 5 6 7 8 9 10 Rubin, Robert H.; Moellering, Robert C. (July 1975). "Clinical, microbiologic and therapeutic aspects of purulent pericarditis". The American Journal of Medicine. 59 (1): 68–78. doi:10.1016/0002-9343(75)90323-X. PMID   1138554.
  5. ↑ Chiabrando, Juan Guido; Bonaventura, Aldo; Vecchié, Alessandra; Wohlford, George F.; Mauro, Adolfo G.; Jordan, Jennifer H.; Grizzard, John D.; Montecucco, Fabrizio; Berrocal, Daniel Horacio; Brucato, Antonio; Imazio, Massimo; Abbate, Antonio (January 2020). "Management of Acute and Recurrent Pericarditis". Journal of the American College of Cardiology. 75 (1): 76–92. doi: 10.1016/j.jacc.2019.11.021 . PMID   31918837. S2CID   210132213.
  6. ↑ Imazio, Massimo; Demichelis, Brunella; Parrini, Iris; Giuggia, Marco; Cecchi, Enrico; Gaschino, Gianni; Demarie, Daniela; Ghisio, Aldo; Trinchero, Rita (2004-03-17). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". Journal of the American College of Cardiology. 43 (6): 1042–1046. doi:10.1016/j.jacc.2003.09.055. ISSN   0735-1097. PMID   15028364.
  7. ↑ Salem, K.; Mulji, A.; Lonn, E. (November 1999). "Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade". The Canadian Journal of Cardiology. 15 (11): 1251–1255. ISSN   0828-282X. PMID   10579740.
  8. 1 2 3 4 5 6 Sagristà-Sauleda, J.; Barrabés, J. A.; Permanyer-Miralda, G.; Soler-Soler, J. (1993-11-15). "Purulent pericarditis: review of a 20-year experience in a general hospital". Journal of the American College of Cardiology. 22 (6): 1661–1665. doi:10.1016/0735-1097(93)90592-o. ISSN   0735-1097. PMID   8227835.
  9. ↑ "The changed spectrum of purulent pericarditis. An 86 year autopsy experience in 200 patients". The American Journal of Medicine. 63 (5): A93. November 1977. doi:10.1016/0002-9343(77)90172-3. ISSN   0002-9343.
  10. ↑ Augustin, Pascal; Desmard, Mathieu; Mordant, Pierre; Lasocki, Sigismond; Maury, Jean-Michel; Heming, Nicholas; Montravers, Philippe (2011-04-20). "Clinical review: intrapericardial fibrinolysis in management of purulent pericarditis". Critical Care (London, England). 15 (2): 220. doi: 10.1186/cc10022 . ISSN   1466-609X. PMC   3219308 . PMID   21575282.
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