72 year old caucasian male presents to the hospital with 2 hours of chest pain.

Pain increased with inspiration, cough and supine position. Pain unrelieved with nitroX3. He denied fever or chills, nausea, vomiting, diaphoresis, palpitations, lightheadedness, or syncope. He had similar chest pain 1 week ago for several days that was also pleuritic in nature. REVIEW OF SYSTEMS:otherwise Negative

PMHx Hypertension Diabetes mellitus Cirrhosis of the liver Upper GI bleeding status post band ligation. SOCIAL HISTORY: Nonsmoker, Past alcoholic/No drug abuse. MEDICATIONS: None. ALLERGIES: NKDA.

Vitals: Blood pressure 125/70, heart rate 108 and regular, respiratory rate 16, Sats 98% RA General:- comfortable, in no respiratory or physical distress Eyes: PERRLA, EOMI Neck: no JVD, no lymphadenopathy/thyromegaly

Chest: clear bilaterally

CV: RRR Grade II/VI midsystolic murmur at the base Abd: soft nontender

Extremities: no edema, no clubbing, +2 pulses

CNS:- Alert orientedX3

Ca: 9.6 240 Mg: 2.1 4.3 20 0.83 PO4: 4.4 13.1 CK: 67, MB: 2, troponin X3 neg 9.2 76 37.2 ESR 80 CRP 128 LFTs, coags: Normal
UA: trace protein, 4+ glucose, 1+ blood, 6 RBC, <1 WBC

129 93

Pt was taken to the cath lab for emergent cath for STEMI. Coronary angiogram deferred as pts history was clearly s/o pericarditis and was started on high dose NSAIDS and colchicine. Echo done on day 2 of admission showed Moderate circumferential pericardial effusion with no definite echocardiographic evidence of tamponade.

On day 3 of admission, pt developed hypotension and was persistently low despite fluids. CCU evaluation called for Vitals:Temp 99.4F HR 102 RR 22 BP 70/40mmhg s/p 1 lt NS Sats 96% on 2L NC.

O/E General:- No acute distress, diaphoretic Eyes: PERRLA, EOMI Neck: Elevated JVD at 8 cm, no lymphadenopathy/thyromegaly Chest: clear bilaterally CV: RRR, Grade II/VI midsystolic murmur at apex, high pitch squeaky sound at left sternal border Abd: soft nontender

Extremities: no edema, no clubbing, +2 pulses

CNS:- Alert orientedX3

Wbc 12.4 with 90% Neutrophils BUN 35 Cr 2.27 Lactate 4.1 ABG 7.31/35/200 ON 4 L o2 Trop 0.01 CK 22 Bnp 407 U/A Negative for infection

CXR

Repeat ECHO compared to prior echocardiogram done previous day showed that there is significant worsening of the pericardial effusion in the past 24 hours, still with no diastolic collapse.

CT CHEST TEE CT SURGERY CONSULT CARDIAC MRI IJ LINE PLACEMENT

CT surgery evaluation called for.. Pt taken for emergent pericardial window.

BLOOD CULTURESx2 POSITIVE Staph aureus MSSA Pericardial fluid cultures positive for MSSA. Negative for fungal cx and AFB Pt initially started on Vancomycin+zosyn switched to Nafcillin and gentamycin. White count as high as 22 and then trended down so did ESR and CRP.

PH 7.6 RBC 7667 Nucleated cells 5111 Segs 98% Lymphocytes 2% LDH 2977 Protein 4.3 Amylase 13 Glucose 170

Purulent pericarditis is defined as a localized infection of the pericardial space characterized by gross pus in the pericardium or microscopic purulence (>20 leukocytes per oil immersion field). Mortality of 40% if untreated in time.

Hematogenous spread mostly Staphylococcus aureus and various streptococci. Pneumonia or empyema may be accompanied by bacteremia.

Extension from a myocardial focus Infective endocarditis complicated by perivalvular ring abscess, septic coronary artery emboli, or myocardial abscess all of which can result in direct extension of infection to the pericardium
Perforating injury or surgery S. aureus, enteric gramnegative rods, and Candida species are the most likely pathogens, polymicrobial. From a subdiaphragmatic suppurative focus Undrained subphrenic abscesses result in pericardial extension in 2 percent of cases. Eg intrahepatic amoebic abscess, ruptured duodenal or gastric ulcer, infected choledochal cyst, peritonitis, or erosion of intraabdominal tumor into the pericardium

TEE ruled out valvular vegetations US abdomen negative for intra-abdominal abcess ?source

???MODES OF DRAINAGE???

Pericardiocentesis is the simplest and often the fastest way to drain the pericardial space. However, thick fluid may either drain poorly or result in loculations in the pericardial space. Furthermore, pericardial constriction may occur following recovery if pericardiocentesis is the primary drainage method. Intrapericardial instillation of fibrinolytics can be used to improve drainage of thick, purulent fluid. Subxiphoid pericardiotomy more complete and permanent drainage, window is created and manual lysis of adhesions and loculations is easily accomplished with the finger of the operating surgeon.

Pericardiectomy Pericardiectomy has a higher morbidity and mortality than subxiphoid pericardiotomy. However, pericardiectomy usually achieves complete drainage, and is frequently required in patients with dense adhesions, loculated and thick purulent effusion, recurrent tamponade, persistent infection, and progression to constriction
Video-assisted thoracic surgery Video-assisted thoracic surgery (VATS) requires intubation and deflation of the left lung. It is usually performed through a small left chest incision. A pericardial window can usually be performed with this procedure, but complete pericardial stripping is not possible.

Antimicrobial therapy Intravenous antimicrobial therapy should be started as soon as the diagnosis of purulent pericarditis is suspected. Empiric regimen Based on most common pathogen in the clinical scenario. These factors include: Whether the patient is immunosuppressed Whether the infection began in a health-care setting or in the community The presence of a concurrent infection at another body site The presence of intravascular lines or prosthetic devices Local patterns of antimicrobial resistance Whether the patient has received recent antimicrobial therapy

Empiric regimens should cover gram postive and gm negative organisms Possible regimens include: Vancomycin +Ceftriaxone (2 g IV once daily), cefotaxime (2 g every eight hours) or gentamicin (3 mg/kg per 24 hours divided equally in two or three doses) OR A carbapenem, such as imipenem (500 mg IV every six hours) or meropenem (1 g IV every eight hours) OR A beta-lactam plus beta-lactamase inhibitor, such as ticarcillin-clavulanate (3.1 g IV every four hours), piperacillin-tazobactam (4.5 g every six hours) or ampicillin-sulbactam (3 g IV every six hours) OR Cefepime (2 g IV every 12 hours)

Empiric therapy with fluconazole (200 to 400 mg intravenously once daily) is recommended for patients who are severely immunosuppressed, have had recent care in an intensive care unit recipients of recent broad-spectrum antimicrobial therapy.

Intravenous therapy should be continued until fever and clinical signs of infection have resolved and until the white blood cell count is normal. In general this usually consists of a total of approximately 2-4 Weeks of therapy, depending on the adequacy of drainage and the antimicrobial susceptibility of the infecting bacteria. There is no role for pericardial instillation of antibiotic, since therapeutic levels in the pericardial fluid are achieved by intravenous administration of antibiotics

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