Purulent pneumococcal pericarditis. A continuing problem in the antibiotic era

The clinical findings in five patients with purulent pneumococcal pericarditis are presented. Predisposing factors were untreated pneumococcal pneumonia and empyema in three patients and congenital hypogammaglobulinemia in one patient. The three patients, in whom the diagnosis was established by pericardiocentesis, recovered without sequelae after surgical drainage of the pericardium and systemic antibiotic therapy. The two remaining patients had unsuspected purulent pericarditis demonstrated postmortem.A review of 113 cases of purulent pneumococcal pericarditis since 1900 was made. A preceding pneumonia was present in 93.1 per cent of the patients; 66.6 per cent had pneumonia with empyema. Signs frequently associated with pericarditis such as a pericardial friction rub, pulsus paradoxus and an enlarged cardiac silhouette may be absent although circulatory embarrassment exists. Pericardiocentesis is mandatory to establish the diagnosis of purulent pneumococcal pericarditis. Although mortality in untreated patients was 100 per cent, the 10 patients treated with both systemic antibiotics and surgical drainage survived.     

Clinical, microbiologic and therapeutic aspects of purulent pericarditis.

Twenty-six patients with purulent pericarditis were seen at the Massachusetts General Hospital between 1960 and 1974. The diagnosis was made in 18 of them during life, but only 6 survived, with an over-all mortality rate of 77 per cent. In eight patients, purulent pericarditis developed in the early postoperative period after thoracic surgery. In seven, purulent pericarditis was the result of contiguous spread of infection from a pleural, mediastinal or pulmonary focus in nonsurgical patients. In five patients, it was the result of direct spread to the pericardium from an intracardiac infection. In the remaining six patients, purulent pericarditis developed as the result of a systemic bactermia. Immunosuppressive therapy, extensive thermal burns, lymphoproliferative disease and other systemic processes affecting host resistance were present in at least half the patients. Staphylococcus aureus was the etiologic agent in the largest number of patients (8 of 26 in this report). However, in contrast to previous studies, in a significant number of the patients (five), purulent pericarditis was the result of fungal infection (in three patients subjected to thoracic surgery and in two immunosuppressed patients). This report confirms that purulent pericarditis is an acute disease with a fulminant course. The diagnosis is easily missed since classic signs of pericarditis (including chest pain, friction rub and diagnostic electrocardiographic abnormalities) may be absent. The echocardiogram shows considerable promise in allowing earlier diagnosis of the pericardial effusion which accompanies purulent pericarditis. Optimal therapy consists of prolonged antibiotic therapy and aggressive drainage of the pericardium. In this series, there were 6 survivors among the 11 patients (55 per cent) who received appropriate therapy.     

Pericardial disease in patients with cancer: The differentiation of malignant from idiopathic and radiation-induced pericarditis

Pericardial disease developed in 31 patients with a variety of malignancies. Half of the patients (58 percent) were found to have malignant pericardial involvement, 32 percent idiopathic pericarditis and 10 percent radiation-related pericarditis. Facial swelling, cardiac arrhythmias and pericardial tamponade occurred frequently in the patients with malignant pericardial disease. Fever, pericardial friction rub and improvement with nonsteroidal anti-inflammatory drugs characterized the patients with idiopathic pericarditis. Effusive-constrictive pericarditis requiring pericardiectomy was noted in patients with radiation-induced disease. Pericardiocentesis documented malignant pericardial disease in 85 percent of patients studied, while 15 percent required open biopsy for diagnosis. Specific therapy directed at malignant pericardial disease may contribute to survival up to one year in 25 percent of patients. In 40 percent of patients with idiopathic pericarditis and in the majority of patients with radiation-induced pericarditis, survival was one year with specific therapy. A systematic evaluation of pericardial disease will benefit a subset of cancer patients with idiopathic pericarditis and radiation-induced pericarditis who can be managed conservatively.     

Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series

Objective:

In the antibiotic era, purulent pericarditis is a rare entity. However, there are still reports of cases of the disease, which is associated with high mortality, and most such cases are attributed to delayed diagnosis. Approximately 40-50% of all cases of purulent pericarditis are caused by Gram-positive bacteria, Streptococcus pneumoniae in particular.

Methods:

We report four cases of pneumococcal pneumonia complicated by pericarditis, with different clinical features and levels of severity.

Results:

In three of the four cases, the main complication was cardiac tamponade. Microbiological screening (urinary antigen testing and pleural fluid culture) confirmed the diagnosis of severe pneumococcal pneumonia complicated by purulent pericarditis.

Conclusions:

In cases of pneumococcal pneumonia complicated by pericarditis, early diagnosis is of paramount importance to avoid severe hemodynamic compromise. The complications of acute pericarditis appear early in the clinical course of the infection. The most serious complications are cardiac tamponade and its consequences. Antibiotic therapy combined with pericardiocentesis drastically reduces the mortality associated with purulent pericarditis.     

Constrictive pericarditis as a complication of coronary artery bypass surgery

Although it is now recognised as a rare complication of cardiac surgery, constrictive pericarditis was diagnosed in three patients after coronary artery bypass surgery. The time interval between cardiac surgery and the development of constrictive features varied from two to six weeks. All three patients presented with severe congestive heart failure. Haemodynamic findings were characteristic of constrictive pericarditis. Pericardial thickening detected by computed tomography in one patient was useful in establishing a definite diagnosis. One of the patients had a serous constrictive effusive pericarditis, and surgical pericardial drainage was needed. The other patient underwent pericardiectomy with preservation of the grafts. The diagnosis of constrictive pericarditis should be considered in patients presenting with unexplained right sided heart failure after cardiac surgery.     

Constrictive pericarditis as a complication of coronary artery bypass surgery.

Although it is now recognised as a rare complication of cardiac surgery, constrictive pericarditis was diagnosed in three patients after coronary artery bypass surgery. The time interval between cardiac surgery and the development of constrictive features varied from two to six weeks. All three patients presented with severe congestive heart failure. Haemodynamic findings were characteristic of constrictive pericarditis. Pericardial thickening detected by computed tomography in one patient was useful in establishing a definite diagnosis. One of the patients had a serous constrictive effusive pericarditis, and surgical pericardial drainage was needed. The other patient underwent pericardiectomy with preservation of the grafts. The diagnosis of constrictive pericarditis should be considered in patients presenting with unexplained right sided heart failure after cardiac surgery.     

Constrictive pericarditis after myocardial revascularization: report of three cases.

Although postoperative constrictive pericarditis is rare, the diagnosis should be considered when unexplained right-sided heart failure develops after cardiac surgery. Within a 6 week interval, evidence of constrictive pericarditis developed in three patients who had recently undergone myocardial revascularization. One patient presented with biventricular failure, pericardial effusion and suspected tamponade. Severe constrictive pericarditis was demonstrated at subsequent operation. An apparent postpericardiotomy syndrome preceded evidence of right heart failure in the other two patients. Etiologic considerations include the possibility that pericardial irrigation with povidone-iodine (Betadine) solution may have contributed to subsequent fibrosis.     

Pericardial disease is often not recognised as a cause of chronic severe ascites

BACKGROUND/AIMS: Severe chronic ascites remains a difficult diagnostic and therapeutic problem. Even in the current era, constrictive pericarditis is an underestimated and sometimes unrecognised cause. Moreover, missing the diagnosis deprives patients of remedial therapy. METHODS: Two cases of calcified constrictive pericarditis, complicated with cirrhosis and diagnosed in a late stage, are described. Due to insufficient clinical appreciation and lack of trust in echocardiography results, performed by cardiologists who were insufficiently familiar with the echocardiographic features of constrictive pericarditis, diagnosis was delayed in the two patients RESULTS: The diagnosis of constrictive pericarditis as a cause of ascites is based upon the clinical signs of right heart failure in a patient with normal systolic left and right ventricular function and a high, serumascitic albumin-content difference. Complementary workup with complete Doppler echocardiography study, right and left heart catheterisation and MRI or cine CT of the heart is necessary to confirm the diagnosis. CONCLUSION: Careful history taking and clinical examination remain the cornerstone of any diagnostic work-up, even in this era of technological refinement.     

Pericarditis complicating acute myocardial infarction: incidence of complications and significance of electrocardiogram on admission

The records of 31 patients with pericarditis complicating acute myocardial infarction were reviewed and compared to a control group of 274 patients with infarction but without pericarditis. The cases of pericarditis all occurred within one week of myocardial infarction and were included only if a typical pericardial friction rub was heard by more than one observer.Sex distribution and age were similar in both groups. There was a higher incidence of anterior wall infarction in the group with pericarditis. The incidence of atrial arrhythmias was less than in controls, while the incidence of ventricular arrhythmias, significant congestive heart failure, and death was slightly greater in those with pericarditis.Maximum ST segment elevation on the day of admission in the group with pericarditis was compared with a control group. In those with anterior wall infarction and pericarditis, the average ST segment elevation in the anterior precordium was 5.6 mm. compared to 2.6 mm. in the controls. In those with inferior wall infarction and pericarditis, the average ST segment elevation was 3.6 mm. in Lead III compared to 1.7 mm. in a control group.It is concluded that patients who develop pericarditis within one week of acute myocardial infarction do not have an increased incidence of atrial arrhythmias. The incidence of ventricular arrhythmias, significant congestive heart failure, and death are slightly greater and may be due to more extensive myocardial infarction. The higher initial ST segment elevation in patients with pericarditis may indicate a greater amount of injury or may be a sign of pericardial involvement that is seen before clinical pericarditis is present.     

Pneumococcal purulent pericarditis

INTRODUCTION: Purulent pneumoccocal pericarditis are extremely rare since the introduction of antibiotics. EXEGESIS: A 59-year-old woman presented to the emergency room with a seven-day history of dyspnea and fever. No signs of heart failure or cardiac friction rub were evidenced. Laboratory tests disclosed elevated acute phase reactants and elevated white blood cells with a high neutrophil count. Chest radiograph showed cardiomegaly and a bilateral pleural effusion. Chest-computed tomography confirmed the pleural effusion and evidenced a large pericardial effusion. Streptoccocus pneumoniae grew up form pericardial fluid and blood cultures. In addition to the pericardial drainage, the patient received intravenous amoxicillin therapy. Outcome was favourable. There was no evidence of immunodeficiency. CONCLUSION: Although exceptional, diagnosis of purulent pneumococcal pericarditis should not be missed as it may compromise vital prognosis. Therapy should combine pericardial drainage and antibiotics.     

Rapid evolution of cardiac tamponade due to bacterial pericarditis in two patients with HIV-1 infection.

We describe two HIV-seropositive patients with acute pneumococcal empyema and pericarditis. Cardiac tamponade evolved rapidly in each patient and was reversed with prompt surgical intervention. In each case, immunologic abnormalities were detected which could have facilitated local spread of infection and progression to tamponade. Pericarditis, an otherwise rare manifestation of pneumococcal infection in the antibiotic era, should be anticipated in HIV-seropositive patients with pneumococcal empyema.     

Constrictive pericarditis in the course of rheumatoid arthritis

We describe a case of a patient with advanced heart failure. On the basis of clinical status, echocardiography and the results of magnetic resonance, constrictive pericarditis was diagnosed. The seropositive rheumatoid arthritis was the cause of the constriction. Constrictive pericarditis should be considered in differential diagnosis in patients with rheumatoid arthritis and heart failure.     

Usefulness of systolic time intervals in differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy.

Systolic time intervals in 15 patients with constrictive pericarditis and seven patients with restrictive cardiomyopathy were compared in order to assess their value in the differential diagnosis of the two disorders. Clinical examination had failed to make the distinction. Right heart catheterization was helpful in diagnosing restriction but failed to differentiate patients with constrictive pericarditis from those with restrictive cardiomyopathy. The systolic time intervals clearly separated the two groups. The PEP/LVET was normal in all patients with constrictive pericarditis (0.34 +/- 0.01) and abnormal in all patients with restrictive cardiomyopathy (0.70 +/- 0.09, P less than 0.001). In 13 patients (five with restrictive cardiomyopathy and eight with constrictive pericarditis) the results of quantitative left ventricular angiocardiography were available. A high correlation (r=-0.90, P less than 0.01) between the PEP/LVET and the ejection fraction confirmed the validity of the PEP/LVET as a measure of left ventricular performance in these patients. Thus the systolic time intervals clearly distinguished between constrictive pericarditis and restrictive cardiomyopathy and are a reliable non-invasive technique for making the difficult differential diagnosis.     

Usefulness of systolic time intervals in differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy.

Systolic time intervals in 15 patients with constrictive pericarditis and seven patients with restrictive cardiomyopathy were compared in order to assess their value in the differential diagnosis of the two disorders. Clinical examination had failed to make the distinction. Right heart catheterization was helpful in diagnosing restriction but failed to differentiate patients with constrictive pericarditis from those with restrictive cardiomyopathy. The systolic time intervals clearly separated the two groups. The PEP/LVET was normal in all patients with constrictive pericarditis (0.34 +/- 0.01) and abnormal in all patients with restrictive cardiomyopathy (0.70 +/- 0.09, P less than 0.001). In 13 patients (five with restrictive cardiomyopathy and eight with constrictive pericarditis) the results of quantitative left ventricular angiocardiography were available. A high correlation (r=-0.90, P less than 0.01) between the PEP/LVET and the ejection fraction confirmed the validity of the PEP/LVET as a measure of left ventricular performance in these patients. Thus the systolic time intervals clearly distinguished between constrictive pericarditis and restrictive cardiomyopathy and are a reliable non-invasive technique for making the difficult differential diagnosis.     

Acute idiopathic pericarditis in the aged.

Eleven elderly patients with idiopathic pericarditis are reported. All but one were older than 60 yr. Evidence of ischemic cardiovascular disease was present in 8 patients. The initial diagnosis was heart failure with pulmonary complications in 4 cases and myocardial infarction in 3. Respiratory infection preceded the onset of pericarditis in 5 cases. Presenting symptoms were typical precordial pain, fever and dyspnea. Pericardial friction was found in 7 cases and transient rhythm disturbances in 5. Four patients had ST elevation and 3 had ST depression in their electrocardiograms. Other findings included an increased sedimentation rate, leukocytosis, elevated venous pressure and normal SGOT levels. Antibiotics were of no avail but prednisone had a dramatic effect. Two patients had a relapsing course lasting 2 yr or more. One patient, who died at the age of 75 from bleeding ulcer, had patent coronary arteries and mild perimyocardial fibrosis. The diagnosis of idiopathic pericarditis in the aged is difficult because the disease simulates ischemic heart disease in patients who frequently have evidence of arteriosclerotic cardiovascular involvment.     

The functional defect in amyloid heart disease. The "stiff heart" syndrome.

Left ventricular performance was studied in three patients with heart failure due to amyloid deposits. The diagnosis of amyloidosis was proved by cardiac biopsy in two patients and by rectal biopsy in the third. One patient had myelomatosis, but the other two had no other identifiable disease. The investigative technique allowed simultaneous measurements of pressure and volume in the left ventricle. The functional defect with slow cardiac filling at high pressure and greatly reduced left ventricular contraction differed from that of constrictive pericarditis and other heart muscle disease. These features of a "stiff heart" are probably unique to amyloidosis and should make possible positive recognition of the condition on the basis of echocardiographic, angiographic and hemodynamic findings.     

Left ventricular filling in differentiating restrictive amyloid cardiomyopathy and constrictive pericarditis

Left ventricular filling was evaluated with use of digitized left ventriculograms in patients with (1) restrictive amyloid cardiomyopathy, (2) constrictive pericarditis, and (3) a normal heart. Restrictive cardiomyopathy (four patients) was established by right and left heart hemodynamic studies and postmortem examination; all four patients had cardiac amyloidosis. Constrictive pericarditis (seven patients) was established by characteristic right and left heart catheterizatlon data and pericardial disease at operation; four patients had calcific and three had noncalcific anatomic changes. Normal subjects (seven patients) had normal intracardiac pressures and normal findings on left ventriculography and coronary arteriography.Left ventriculographic silhouettes were digitized and left ventricular volumes were calculated by computer at 16 ms intervals. Curves of left ventricular volume and ventricular filling rate were constructed for each patient and also for each group. Patients with restrictive amyloid cardiomyopathy had no plateau in the diastollc left ventricular filling volume curve, and their left ventricular filling rate was slower than normal during the first half of diastole. Patients with constrictive pericarditis had a sudden and premature plateau in the diastolic left ventricular volume filling curve. In addition, the left ventricular filling rate was faster than normal during the first half of diastole. Statistical analysis of left ventricular filling rate in patients with restrictive amyloid cardiomyopathy, patients with constrictive pericarditis and normal patients showed significant differences during the first half of diastole; those with restrictive amyloid cardiomyopathy had 45 ± 4 percent, those with constrictive pericarditis had 85 ± 4 percent and normal subjects had 65 ± 5 percent of left ventricular filling completed at 50 percent of diastole (p < 0.05).Thus, this study showed a significantly different profile of diastolic left ventricular filling volume and ventricular filling rate curves during the first half of diastole in patients with restrictive cardiomyopathy and those with constrictive pericarditis. The findings suggest the importance of these determinations in differentiating restrictive amyloid cardiomyopathy and constrictive pericarditis at cardiac catheterization.     

套式聚合酶链反应快速诊断结核性心包炎

快速诊断结核性心包炎以便及早抗痨治疗防止缩窄性心包炎的发生。应用套式聚合酶链反应（Ｎｅｓｔｅｄ－ ＰＣＲ） 、直接涂片、培养对８３ 例心包积液标本进行结核菌检测。结果：结核性心包积液Ｎｅｓｔｅｄ － ＰＣＲ阳性率为７２ ．５ ％ 、培养阳性率为１９ ．６ ％ 、涂片镜检阳性率为２３ ．５ ％ 。非结核性心包积液无１ 例阳性。Ｎｅｓｔｅｄ－ ＰＣＲ特异性好、敏感性强并可能避免一般聚合酶链反应（ＰＣＲ） 所出现的假阳性     

Percutaneous myocardial and pericardial biopsy with the Menghini needle

A simple, safe method of obtaining myocardial or pericardial tissue for analysis by light or electron microscopy or for culture has obvious application. The Menghini needle has been demonstrated to be a safe and effective instrument for the aspiration biopsy of liver and kidney. Therefore, application of aspiration biopsy with a 17 gauge Menghini needle to the heart by means of the left ventricular apical percutaneous approach has been evaluated in humans in 27 myocardial and 8 pericardial biopsies. Adequate tissue was obtained in all except one pericardial and two myocardial biopsy attempts. Of the eight pericardial biopsies, the diagnosis of tuberculous pericarditis was made in two cases and carcinomatous invasion of the pericardium was made in another two cases. Three cases showed nonspecific pericarditis. Of the 27 myocardial biopsies, 6 were examined by light microscopy and 21 were examined by electron microscopy. Light microscopy revealed no specific findings. However, electron microscopy showed moderate to severe intracellular abnormalities, the significance of which remains to be determined. Biopsy procedure takes 5 minutes or less under local anesthesia following mild premedication. Pneumothorax occurred in two patients and transient mild pleuritic chest pain occurred in four patients. Both complications were well tolerated. The technique seems effective and safe. Its utility and application remain to be determined.     

Pneumococcal endocarditis is not just a disease of the past: an analysis of 16 cases diagnosed in Denmark 1986-1997

To remind clinicians and clinical microbiologists of the clinical features and therapeutic aspects of pneumococcal endocarditis, patients with pneumococcal endocarditis from 1986 to 1997 were identified via an enquiry to clinical microbiologists across Denmark. For all patients records were reviewed to confirm the diagnosis of pneumococcal endocarditis, and the clinical course, therapy and outcome were analysed. 16 patients with definitive pneumococcal endocarditis were found. All pneumococcal isolates were sensitive to penicillin. 15 patients had no previously known cardiac valvular disease, 10 patients had X-ray-proven pneumonia and 5 had meningitis. The aortic valve was affected in 13 patients, of whom 12 developed aortic insufficiency and 11 cardiac failure. Of 7 patients who underwent surgery, 6 needed immediate cardiac valve replacement. The 30-day case fatality rate was 19% (95% confidence limits 4-46%). Pneumococcal endocarditis must be considered when treating patients with pneumococcaemia. The most important clue to the diagnosis is a significant murmur and development of heart failure. Evaluation by transoesophageal echocardiography is helpful in determining the diagnosis and assessing the need for surgical intervention. With appropriate antibiotic therapy, close observation and cardiac valve replacement if necessary, the prognosis is better than recorded in earlier studies.