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Acute suppurative amebic pericarditis
LETTERS TO THE EDITOR
ACUTE SUPPURATIVE
AMEBIC PERICARDITIS
If the bibliography of Costa et al.’ included 1972 publications, the authors ignored 11 cases published in 19722 as did the reviewing editor of the Journal. Our group2-4 has described 17 patients, of whom 7 survived, emphasizing that the clinical findings can suggest progressive myocardial compression or cardiac tamponade, with or without sepsis, in patients with or without a diagnosis of amebic abscess of the liver or a past medical history of dysentery and that the pus may not be reddish-brown or resemble anchovy sauce. We believe that the latter points have previously been overstressed and their absence may mislead some clinicians since a high degree of suspicion is required in addition to the use of all available diagnostic tools such as liver scan and serologic tests to confirm the diagnosis. We do not agree that “conservative management” is advisable in the early stage of the lesion, although this statement seems to be in conflict with an earlier statement: “early drainage is advised”; in our more recent cases, including two unreported ones, early subxyphoid drainage516 proved easy and lifesaving and permitted the correct diagnosis or its confirmat.ion. Amebic abscesses of the liver can open into the pericardium, thus causing the death of a patient who is under proper medical therapy; surgical maneuvers might be needed to prevent this complication. Finally, a philosophical consideration. Can the authors of a paper ignore a similar publication of a larger series, and the journal receiving the paper ignore such an omission? Should the burden be placed on the authors, or is the reviewer to be blamed when statements as “up to 1972 only 80 cases were reported” and 11 more, published that same year in an international journal are not mentioned? Carlos Ibarra-P&ez, MD, FACC
formed in the case reported. If this measure is combined with proper early diagnosis and medical treatment, a good survival rate may be achieved. The statement recommending conservative management refers to classic open chest pericardiectomy in the early stages of constrictive pericarditis, which may develop shortly after the acute phase, as happened in our case: the reported mortality rate for this procedure is very high. We have now had the opportunity to read the paper of Ibarra-Perez et al., which would have been included in our reference list if we had been aware of it earlier. However, how large a reference list should be is also a matter of philosophy. The main objective of our report was to offer a well documented case of an uncommon condition, emphasizing the following points: (1) the clinical presentation primarily as acute pericarditis with tamponade; (2) the possibility of confusion with the more common acute tuberculous pericarditis; (3) the need for early open pericardial drainage, since signs of severe cardiac compression have a tendency to recur in this condition; (4) the simple way to visualize by X-ray film the liver abscess by injecting contrast material through the tube placed into the pericardial cavity; (5) the need, despite treatment with appropriate doses of chloroquine (Aralen@) and metronidazole (Phlagyl@) for treatment with emetine hydrochloride to achieve complete recovery from the acute phase; and (6) the possibility of early development of constrictive pericarditis. Thus, in light of these objectives, once a certain number of papers giving support to these points were found, the reference list was considered satisfactory. Armenio Costa Guimarles, MD Lucia S. Azevedo Vinhaes, MD Ademar Santos Filho, MD Jo& PBricles Esteves, MD Waldeck Neves Abreu, MD Hemodynamic Research Laboratory Hospital Prof. Edgard Santos University of Bahia School of Medicine Bahia, Brazil
Division of Surgery Hosp. de Enfermedades del T&ax Centro Medico National. lnstituto Mexican0 del Seguro Social MCxico City, M(txico References 1. Cosla A, Acevedo L, Santos A, et al: Acute suppurative amebic pericarditis. Am J 2.
3. 4. 5. 6.
Cardiol 34:103. 1974 Ibarra-Pber, Green L, Calvillo M, et al: Diagnosis and treatment of rupture of amebic abscess of the liver into the pericardium. J Thorac Cardiovasc Surg 64: 11, 1972 Dlar G, Arguer0 R, Gutlerrez R, et al: Pericarditis amibiana, comunicacibn de 3 cases. Neumol Cir Tbrax (f&x.) 32393. 1971 Maldonado H. Martinez R, Taracena A, et al: Absceso hepatico abier to a pericardio. Neumol Cir Tbrax (Mex.) 33: 19, 1972 Green L, Ibarra-Perez C: Siopsia y drenaje del pericardio Prensa Med (Mex.) 36:37. 1971 Fontanella LJ, Cuello L, Dooley 8: Subxyphoid pericardial window. J Thorac CardioYasc Surg 62:95. 1971
REPLY Our statement recommending conservative management in the early stages of the lesion does not “conflict” with our recommendation for early open pericardial drainage; the two statements are not related. The second one refers to early drainage of the pericardial sac through a tube, as per-
September
References 1. Macleod IN, Wllmot AJ, Powel SJ: Amoebic pericardltis. C! J Med 35:293-310, 1966 2. Ibarra-Perez, C. Green SL, Calvlllo-Juarez, M, et al: Diagnosis and treatment of rupture of amebic abscess of the liver into the pencardium J Thorac Cardiovasc Surg 64:i l-16, 1972
SEQUENTIAL
STUDIES OF LEFT VENTRICULAR FUNCTION
McAnulty et al.’ offer a wealth of information, previously unavailable, on the reproducibility (or lack of it) of commonly recorded parameters of ventricular function. Their conclusion that “The range of these day to day changes in the parameters of left ventricular function without therapeutic intervention must be considered when evaluating the effect of therapy” is of interest to physicians and surgeons alike. Furthermore, their finding that “wall motion abnormalities (instead) were constant in site and showed little variation in extent” will be received with enthusiasm by those of us who had insisted on the value, simplicity and
1975
The American
Journal
of CARDIOLOGY
Volume 36
409
ACUTE SUPPURATIVE
AMEBIC PERICARDITIS
If the bibliography of Costa et al.’ included 1972 publications, the authors ignored 11 cases published in 19722 as did the reviewing editor of the Journal. Our group2-4 has described 17 patients, of whom 7 survived, emphasizing that the clinical findings can suggest progressive myocardial compression or cardiac tamponade, with or without sepsis, in patients with or without a diagnosis of amebic abscess of the liver or a past medical history of dysentery and that the pus may not be reddish-brown or resemble anchovy sauce. We believe that the latter points have previously been overstressed and their absence may mislead some clinicians since a high degree of suspicion is required in addition to the use of all available diagnostic tools such as liver scan and serologic tests to confirm the diagnosis. We do not agree that “conservative management” is advisable in the early stage of the lesion, although this statement seems to be in conflict with an earlier statement: “early drainage is advised”; in our more recent cases, including two unreported ones, early subxyphoid drainage516 proved easy and lifesaving and permitted the correct diagnosis or its confirmat.ion. Amebic abscesses of the liver can open into the pericardium, thus causing the death of a patient who is under proper medical therapy; surgical maneuvers might be needed to prevent this complication. Finally, a philosophical consideration. Can the authors of a paper ignore a similar publication of a larger series, and the journal receiving the paper ignore such an omission? Should the burden be placed on the authors, or is the reviewer to be blamed when statements as “up to 1972 only 80 cases were reported” and 11 more, published that same year in an international journal are not mentioned? Carlos Ibarra-P&ez, MD, FACC
formed in the case reported. If this measure is combined with proper early diagnosis and medical treatment, a good survival rate may be achieved. The statement recommending conservative management refers to classic open chest pericardiectomy in the early stages of constrictive pericarditis, which may develop shortly after the acute phase, as happened in our case: the reported mortality rate for this procedure is very high. We have now had the opportunity to read the paper of Ibarra-Perez et al., which would have been included in our reference list if we had been aware of it earlier. However, how large a reference list should be is also a matter of philosophy. The main objective of our report was to offer a well documented case of an uncommon condition, emphasizing the following points: (1) the clinical presentation primarily as acute pericarditis with tamponade; (2) the possibility of confusion with the more common acute tuberculous pericarditis; (3) the need for early open pericardial drainage, since signs of severe cardiac compression have a tendency to recur in this condition; (4) the simple way to visualize by X-ray film the liver abscess by injecting contrast material through the tube placed into the pericardial cavity; (5) the need, despite treatment with appropriate doses of chloroquine (Aralen@) and metronidazole (Phlagyl@) for treatment with emetine hydrochloride to achieve complete recovery from the acute phase; and (6) the possibility of early development of constrictive pericarditis. Thus, in light of these objectives, once a certain number of papers giving support to these points were found, the reference list was considered satisfactory. Armenio Costa Guimarles, MD Lucia S. Azevedo Vinhaes, MD Ademar Santos Filho, MD Jo& PBricles Esteves, MD Waldeck Neves Abreu, MD Hemodynamic Research Laboratory Hospital Prof. Edgard Santos University of Bahia School of Medicine Bahia, Brazil
Division of Surgery Hosp. de Enfermedades del T&ax Centro Medico National. lnstituto Mexican0 del Seguro Social MCxico City, M(txico References 1. Cosla A, Acevedo L, Santos A, et al: Acute suppurative amebic pericarditis. Am J 2.
3. 4. 5. 6.
Cardiol 34:103. 1974 Ibarra-Pber, Green L, Calvillo M, et al: Diagnosis and treatment of rupture of amebic abscess of the liver into the pericardium. J Thorac Cardiovasc Surg 64: 11, 1972 Dlar G, Arguer0 R, Gutlerrez R, et al: Pericarditis amibiana, comunicacibn de 3 cases. Neumol Cir Tbrax (f&x.) 32393. 1971 Maldonado H. Martinez R, Taracena A, et al: Absceso hepatico abier to a pericardio. Neumol Cir Tbrax (Mex.) 33: 19, 1972 Green L, Ibarra-Perez C: Siopsia y drenaje del pericardio Prensa Med (Mex.) 36:37. 1971 Fontanella LJ, Cuello L, Dooley 8: Subxyphoid pericardial window. J Thorac CardioYasc Surg 62:95. 1971
REPLY Our statement recommending conservative management in the early stages of the lesion does not “conflict” with our recommendation for early open pericardial drainage; the two statements are not related. The second one refers to early drainage of the pericardial sac through a tube, as per-
September
References 1. Macleod IN, Wllmot AJ, Powel SJ: Amoebic pericardltis. C! J Med 35:293-310, 1966 2. Ibarra-Perez, C. Green SL, Calvlllo-Juarez, M, et al: Diagnosis and treatment of rupture of amebic abscess of the liver into the pencardium J Thorac Cardiovasc Surg 64:i l-16, 1972
SEQUENTIAL
STUDIES OF LEFT VENTRICULAR FUNCTION
McAnulty et al.’ offer a wealth of information, previously unavailable, on the reproducibility (or lack of it) of commonly recorded parameters of ventricular function. Their conclusion that “The range of these day to day changes in the parameters of left ventricular function without therapeutic intervention must be considered when evaluating the effect of therapy” is of interest to physicians and surgeons alike. Furthermore, their finding that “wall motion abnormalities (instead) were constant in site and showed little variation in extent” will be received with enthusiasm by those of us who had insisted on the value, simplicity and
1975
The American
Journal
of CARDIOLOGY
Volume 36
409