Purulent pericarditis: clinical profile and outcome following surgical drainage and intensive care in children in Chandigarh

Pericardial Disease in the Developing World

Pericardial disease in the developing world is dominated primarily by effusive and constrictive syndromes and contributes to the acute and chronic heart failure burden in many regions. The confluence of geography (location in the tropics), a significant burden of diseases of poverty and neglect, and a significant contribution of communicable diseases to the general burden of disease is reflected in the wide etiological spectrum of causes of pericardial disease. The prevalence of Mycobacterium tuberculosis in particular, is high throughout much of the developing world where it is the most frequent and important cause of pericarditis and is associated with significant morbidity and mortality. Acute viral/idiopathic pericarditis, which is the primary manifestation of pericardial disease in the developed world is believed to occur significantly less frequently in the developing world. Although diagnostic approaches and criteria to establish the diagnosis of pericardial disease are similar throughout the globe, resource constraints such as access to multimodality imaging and hemodynamic assessment are a major limitation in much of the developing world. These important considerations significantly influence the diagnostic and treatment approaches, and outcomes related to pericardial disease.

Purulent pericarditis in children: is pericardiotomy needed?

OBJECTIVES

This study aimed to describe our experience with pediatric bacterial pericarditis and review the optimal therapy for this entity.

METHODS

This is a retrospective study in a pediatric intensive care unit in a university hospital. Three children were diagnosed with purulent pericarditis. They were all treated with antibiotics, echocardiography-guided pericardial fluid drainage, and placement of a pericardial catheter, with no need for thoracotomy or pericardial window.

RESULTS

All 3 children fully recovered, and none developed constrictive pericarditis.

CONCLUSIONS

Children with purulent pericarditis usually can be treated with antibiotics and drainage of pericardial effusion, with no need for thoracotomy or pericardial window.

Purulent pericarditis: report of 2 cases and review of the literature

Purulent pericarditis, a localized infection within the pericardial space, has become a rare entity in the modern antibiotic era. Although historically a disease of children and young adults, this is no longer the case: the median age at the time of diagnosis has increased by nearly 30 years over the past 6 decades. Despite advances in diagnostic and treatment modalities, purulent pericarditis remains a life-threatening illness. Unfortunately, the diagnosis is made postmortem in more than half the cases. Thus, a high index of clinical suspicion is crucial. We present 2 cases of purulent pericarditis, and provide an updated review of other case series published over the past 60 years.

An unusual complication of pneumococcal pneumonia: Acute tamponade due to purulent pericarditis

The incidence of purulent pericarditis has declined, however mortality remains high. Few cases so far of cardiac tamponade related with purulent pericarditis which is a rare complication of pneumococcal pneumonia have been published in the literature. We report a case of the development of cardiac tamponade due to pneumococcal pneumonia and emphasize the importance of early recognition, prompt institution of appropriate antibiotic therapy, and early surgical drainage for survival.

Thoracoscopic Pericardiectomy for Purulent Pericarditis: Experience with 21 Cases

PURPOSE

We present our experience in performing thoracoscopic pericardiectomy for purulent pericarditis in 21 children.

MATERIALS AND METHODS

Pericardiectomy was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at 2-4 mm Hg. Anterior pericardiectomy was performed from the left phrenic nerve to the right border of the sternum to free the anterior part of the heart, notably the cardiac apex and the original area of the great vessels. Purulent debris was removed prior to detaching the epicardial peel.

RESULTS

This study included 21 patients. Their mean age was 8 years. The time from onset of the disease to surgery ranged from 4 to 34 days (average, 15.2 days). Operative times ranged from 50 to 180 minutes (average, 100 minutes). There were no intraoperative or postoperative complications. All symptoms of cardiac tamponade disappeared immediately postoperatively. Follow-up ranged from 4 to 15 months and showed normal clinical manifestations, echocardiographs, and chest x-rays in all children.

CONCLUSION

Thoracoscopic pericardiectomy with removal of a generous amount of the pericardium is feasible and safe for purulent pericarditis.

Staphylococcal pericarditis in a chronic renal failure patient

A 34-year-old female with end-stage renal disease was admitted for severe metabolic acidosis, uremic encephalopathy, pericarditis and severe anemia following a bout of acute gastroenteritis. She improved on aggressive medical management including intensive hemodialysis and was initiated onto maintenance heparin-free hemodialysis (twelve hours per week) and discharged. After a week, she presented with fever with chills and rigors for three days, was toxic, severely orthopenic and had a pulsus paradoxus of 36 mmHg. Echocardiography suggested cardiac tamponade. Aspiration revealed frank pus with polymorphonuclear predominance and Staphylococcus aureus on culture. CT of the thorax revealed pericardial effusion. In the absence of any obvious septic foci, concomitant pleuro-pulmonary sepsis, mediastinal or intra-abdominal pathology; a diagnosis of "acute primary purulent pericarditis" was made. Patient was put on parenteral antibiotics-ceftriaxone and metrogyl. Vancomycin was added after sensitivity results. Pericardial drainage was required initially. After toxemia improved, paradox decreased and fever subsided, the pericardial catheter was removed and antibiotics continued for a period of four weeks. Maintenance hemodialysis was continued during hospital stay and after discharge.

The changing aetiological spectrum of pericarditis in children

The aetiologies, clinical features and follow-up data of 62 children with pericarditis admitted to a university hospital during a 6-year period were retrospectively assessed. Uraemic pericarditis was the most frequent and infections the second most frequent cause. In this series, the proportion of children with purulent pericarditis is less than in previous reports from developing countries. Familial Mediterranean fever, neoplasias, acute rheumatic fever and post-pericardiotomy syndrome were other important causes of pericarditis.