Case Presentation: Purulent pericarditis is rare in the post-antibiotic era. Even rarer is purulent pericarditis caused by Streptococcus Constellatus causing purulent pericarditis in an immunocompetent patient. Here we present a case of an immunocompetent patient who acquired this infection from an unknown source and deteriorated rapidly in spite of optimal medical therapy.A 68-year-old female presented to the hospital with sudden onset chest pain. Upon initial workup, she was found to have pericardial effusion and pericarditis which were treated with colchicine. The patient subsequently worsened over the course of several days, and by day 5 of admission was noted to have increased work of breathing with hemodynamic instability. A stat echocardiogram revealed a worsening effusion which was now loculated with tamponade physiology. Emergent pericardiocentesis was performed which drained purulent fluid. Pericardial fluid culture grew Streptococcus Constellatus. Despite being treated with broad-spectrum antibiotics and maximum vasopressor support, the patient deteriorated quickly and expired.
Discussion: Purulent pericarditis is a life threatening pathology with 100% mortality when left untreated. Complications of purulent pericarditis include cardiac tamponade and florid sepsis, which can lead to rapid deterioration of the patient as seen in our case report. Due to its high mortality, this pathology is often identified postmortem.The most common route by which purulent pericarditis develops is via direct spread. Common etiologies include pneumonia or an intracardiac source. Though hematogenous spread is possible, it is far less common. Streptococcus constellatus, suspicious for a dental source of infection with a hematogenous spread.
Conclusions: Our case emphasizes the importance of early diagnosis and treatment of purulent pericarditis. Given the rarity of this disease, treatment is guided based on case reports and small retrospective studies. Pericardiectomy has been demonstrated to result in better clinical outcomes and prevention of constrictive pericarditis compared to pericardiocentesis alone. However, select studies suggest similar outcomes when intrapericardial fibrinolysis is administered. As pericardiectomy is major surgery, perhaps the less invasive intrapericardial fibrinolysis is favored. Further studies are required to determine the optimal management for this potentially fatal complication of bacterial pericarditis.