Purulent pericarditis as a complication of pneumonia in an infant. clinical case report

ABSTRACT Introduction: Purulent pericarditis is an inflammatory process in the pericardium caused by bacterial infection. If experienced during childhood and with untimely diagnosis, it has a high mortality rate. Case presentation: A 10-month-old infant was admitted to a high complexity pediatric hospital in the city of Bogotá D.C, Colombia, due to clinical symptoms including cough, respiratory distress and fever. A chest x-ray was taken showing cardiomegaly and multilobar pulmonary involvement. The echocardiogram showed global pericardial effusion managed with pericardiotomy, in which 50 mL of turbid fluid with whitish membranes was obtained. Cytochemical test revealed 2 600 mm3 leukocytes with 90% PMN and protein elevation. Purulent pericarditis was diagnosed based on imaging and laboratory findings. Treatment was initiated with ceftriaxone and clindamycin for four weeks, obtaining effective clinical and echocardiographic resolution. Discussion: The clinical presentation and imaging, paraclinical and electrocardiographic findings suggested purulent pericarditis as the first possibility. This diagnosis was confirmed considering the characteristics of the pericardial fluid, which was compatible with an exudate. Clinical resolution supported by antibiotic management corroborated the diagnosis, even though microbiological isolation was not obtained in cultures. Conclusion: Purulent pericarditis is a rare disease in pediatrics and has a high mortality rate. Making a timely diagnosis and administering early treatment are related to a better prognosis of this pathology.

RESUMEN Introducción. La pericarditis purulenta es un proceso inflamatorio del pericardio producto de una infección bacteriana. De no lograrse un diagnóstico oportuno, se convierte en una patología con alta mortalidad en la infancia. Presentación del caso. Lactante de 10 meses de edad que ingresó a un hospital pediátrico de alta complejidad en Bogotá D.C., Colombia, por un cuadro clínico dado por tos, dificultad respiratoria y fiebre. Se tomó una radiografía de tórax donde se observó cardiomegalia y compromiso neumónico multilobar. El ecocardiograma mostró un derrame pericárdico global que requirió pericardiotomía, en la cual se obtuvo 50 mL de líquido turbio con membranas blanquecinas. En la prueba citoquímica se encontraron 2 600mm3 leucocitos, polimorfonucleares del 90% y elevación de proteínas. Con los hallazgos de imagenología y laboratorio se hizo el diagnóstico de pericarditis purulenta, por lo que se inició tratamiento con ceftriaxona y clindamicina por 4 semanas, obteniendo una resolución clínica y ecocardiográfica efectiva. Discusión. La presentación clínica y los hallazgos imagenológicos, paraclínicos y electrocardiográficos sugirieron como primera posibilidad pericarditis purulenta, lo cual se confirmó por las características de líquido pericárdico, que era compatible con un exudado. La resolución clínica, apoyada por el manejo antibiótico y a pesar de no obtener aislamiento microbiológico en los cultivos, corroboró el diagnóstico. Conclusiones. La pericarditis purulenta es una enfermedad poco frecuente en pediatría pero con alta mortalidad. Realizar un diagnóstico oportuno sumado a un tratamiento tempano se relaciona con un mejor pronóstico de esta patología.

Análise epidemiológica das pericardiotomias realizadas em um hospital universitário de Curitiba / Epidemiological analysis of pericardiotomys held in a university hospital of Curitiba

OBJETIVO: Analisar epidemiologicamente a utilização da janela pericárdica(JP) no diagnóstico de lesão cardíaca em um hospital universitário de trauma de Curitiba. MÉTODOS: Estudo observacional, retrospectivo, de análise dos prontuários de pacientes que foram submetidos a pericardiotomia por trauma contuso ou penetrante, no período de seis anos, no serviço de Urgência e Emergência do Hospital Universitário Cajuru. RESULTADOS: 120 pacientes foram submetidos à Janela Pericárdica no período acima referido. A faixa etária variou de 15 a 80 anos, sendo a maior prevalência entre os 20 a 30 anos (49,7 por cento), 105(87,5 por cento) pacientes eram homens e 15(12,5 por cento) mulheres. Os traumas fechados foram 14(11,67 por cento) e penetrantes 105(87,5 por cento). Dos penetrantes, 41 foram por ferida de arma branca, 60 por ferida de arma de fogo e quatro por ambas. Quanto à localização das lesões: 47,5 por cento foram precordiais, 34,16 por cento em transição tóraco-abdominal, 5,0 por cento em ambas e 13,33 por cento em outras localizações. Das JP realizadas, 72,5 por cento foram negativas e 27,5 por cento positivas. Dentre as positivas, as lesões cardíacas encontradas foram: átrio direito 21,2 por cento, ventrículo direito 30,3 por cento, ventrículo esquerdo 24,2 por cento, aorta ascendente 3 por cento, nenhuma lesão 21,2 por cento. Houve 35 óbitos: 18 deles até 24hs e 17 após 24hs. CONCLUSÃO: A janela pericárdica foi mais realizada em homens jovens com ferimentos penetrantes por arma de fogo, em sua maioria com lesão do ventrículo direito como principal achado, concordando com a literatura revisada.

OBJECTIVE: Epidemiologically analyze the use of the pericardiostomy in the diagnosis of cardiac injury in a trauma universitary hospital in Curitiba. METHODS: Observacional, retrospective study, analyzing medical records of patients who were submitted to penetrating or blunt trauma, in a period of 06 years, in Urgency and Emergency unit of Cajuru Universitary Hospital. RESULTS: 120 patients had been submitted to pericardiostomy in the period above related. The age group varied from 15 to 80 years, the major prevalence between 20 and 30 years (49.7 percent), 105 patients were men and 15 women. Blunt trauma corresponded to 14 patients and penetrating to 105 patients. From penetrating ones, 41 patients were inflicted by stabwound, 60 by gunshot wound and 4 by both. About injury sites: 47.5 percent had been precordial, 34.16 percent in thoraco-abdominal transistion, 5.0 percent in both and 13.33 percent in other sites. From the accomplished JP, 72.5 percent had been negative and 27.5 percent positive. Among the positive, cardiac injuries diagnosed by immediate thoracotomy were: right atrium 21.2 percent, right ventricle 30.3 percent, left ventricle 24,2 percent, ascending aorta 3 percent, no injury 21.2 percent. 35 patients died: 18 of them up to 24hs and 17 after 24hs. CONCLUSION: The pericardiostomy were performed mostly in young men with penetrating trauma caused by gunshot wounds., in its majority with injury of the right ventricle as main finding, which agreed to the reviwed literature.

Percutaneous Pericardiostomy and Trastuzumab Monotherapy for Treating Pericardial Metastasis from Breast Cancer and this Presented as Cardiac Tamponade

Although autopsy studies suggest that malignant pericardial effusion is present in up to 15% of the patients suffering with malignancies, symptomatic pericardial effusion presenting as a first manifestation of systemic recurrence in a breast cancer patient is a rare condition. Symptomatic malignant pericardial effusion requires prompt attention and intervention since it can lead to the cardiac tamponade. Treatment of symptomatic pericardial effusion includes pericardial decompression and systemic or intrapericardial chemotherapy. We recently experienced a patient with early breast cancer who developed cardiac tamponade from malignant pericardial effusion as a first manifestation of systemic recurrence 4 years after her initial surgery. The patient was treated with percutaneous pericardiocentesis and she subsequently received systemic trastuzumab. After 6 cycles of trastuzumab, the follow-up CT showed complete disappearance of the pericardial effusion and the mediastinal lymph nodes.