Pericarditis purulenta y empiema pleural por Streptococcus pneumoniae
- B Suberviola Cañas, JC Rodríguez Borregan, A González Castro, E Miñambres, FJ. Burón Mediavilla
- An Med Interna (Madrid)
Purulent pericarditis is a rarely-seen clinical entity characterized by a purulent pericardial effusion, and which is generally produced by the extension of a nearby bacterial infection locus or by blood dissemination. Primary infection is rare.1 The clinical profile is very severe and tends to progress to cardiac tamponade2 or else it is the first clinical manifestation. We present the case of an 81 year old female patient with no relevant medical history who was admitted with the diagnosis of heart failure triggered by a respiratory infection and with a non-specific condition of discomfort and weakness that had been developing over 1 month, and dyspnea with effort, which progressed to dyspnea at rest, had developed in the days before she was admitted. She experienced occasional unproductive coughing and had no measurable fever. Laboratory tests showed: hemoglobin 11.9 g/ dL, haematocrit 36.8%, and leukocytosis, with 16.8 ×109/L (3% band neutrophils), 705 ×109 platelets/L, and fibrinogen, 464 mg/dL. Thoracic radiography showed an enlarged heart with a slight redistribution in both bases. The ECG showed low QRS voltage and diffuse T-wave flattening. Twenty-four hours later, she had deteriorated clinically and showed clinical and hemodynamic signs of cardiac tamponade, hypertension, pulsus paradoxus, and high venous pressure data. A transthoracic echocardiogram was performed, which confirmed the severe pericardial effusion and the data reflecting cardiac tamponade with collapsed right cavities. After several failed attempts to perform echocardiogram-guided pericardiocentesis using the subxiphoid approach, which served to extract a small amount of purulent-looking matter but did not confirm its location in the pericardial cavity, we observed a left-side submammary mass extending caudally toward the abdomen. We then ran a thoraco-abdominal CT scan, and it revealed a large cystic lesion on the left hepatic lobe which extended to the pericardium (Figure). The surgeon then performed another evacuation pericardiocentesis guided through the left parasternal approach and extracted 1000 mL of purulent matter. An emergency open laparotomy was then performed, revealing the abscessed hydatid liver cyst destroying the diaphragm and communicating with the pericardium. After draining, a pericystectomy was performed and the pericardium was cleansed.