A 59–year–old Caucasian male presented with progressive shortness of breath and productive cough for 2 weeks along with low–grade fever. He denied any chest pain. Past history was significant for type 2 diabetes mellitus and chronic kidney disease. He was afebrile with mild tachycardia. There was no pulsus paradoxus and jugular venous distension. Decreased air entry over left lung base and distant heart sounds were heard without any pericardial friction rub. He had leukocytosis and a troponin of 0.55 ng/mL. EKG showed nonspecific ST changes. Chest X–ray showed cardiomegaly with left sided pleural effusion and suspicious infiltrates. The patient was admitted to the Coronary Care Unit for community acquired pneumonia and NSTEMI. He continued to be dyspneic and tachycardic and an EKG revealed electrical alternans. An echocardiogram showed massive pericardial effusion with cardiac tamponade and he underwent an emergent subxiphoid pericardial window with drainage of 500 cc of cloudy and brown pericardial fluid. Broad–spectrum antibiotics were started. A CT chest showed small pericardial effusion, left pleural effusion and left basilar consolidation. Pericardial fluid culture grew Group B Streptococcus agalactiae sensitive to Ceftriaxone. He was subsequently discharged home on intravenous Ceftriaxone for 6 weeks. The pericardial fluid cytology was negative for malignant cells but was consistent with purulent acute inflammatory process. Echocardiogram done at 6 weeks showed a normal appearing pericardium with no pericardial effusion.
Purulent pericarditis is an uncommon entity usually seen in association with pneumonia in a person with conditions like diabetes and chronic kidney disease. Most cases are caused by Staphylococcus aureus and Streptococcus pneumoniae. A handful of cases due to Streptococcus agalactiae have been reported with only a few being complicated by cardiac tamponade. It is not always associated with characteristic features of acute pericarditis like chest pain, friction rub or EKG changes like diffuse ST elevation. Common complications include cardiac tamponade and constrictive pericarditis. Echocardiogram helps in ruling out tamponade. The only way to definitively diagnose it is to obtain pericardial fluid for culture and direct microscopy and this procedure can be both diagnostic and therapeutic in case of associated tamponade. Antimicrobial therapy should be started as soon as the diagnosis is suspected.
This vignette highlights an unusual case of purulent pericarditis with cardiac tamponade due to Streptococcus agalactiae and also shows how this diagnosis may get overlooked on initial presentation.
Figure 1Chest X–ray showing cardiomegaly with left sided pleural effusion and suspicious infiltrates.