- Email: [email protected]
Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound
YAJEM-56663; No of Pages 3 American Journal of Emergency Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound Mackenzie Gabler, MD Wright State University Department of Emergency Medicine, 3525 Southern Blvd, Kettering, OH 45429, United States
a r t i c l e
i n f o
Article history: Received 18 December 2016 Received in revised form 23 April 2017 Accepted 26 April 2017 Available online xxxx Keywords: Purulent pericarditis Cardiac tamponade Endocarditis Emergency department ultrasound
a b s t r a c t Purulent pericarditis is a rare but devastating disease process and even when treated, carries a poor prognosis. Cardiac tamponade is the most severe complication of purulent pericarditis and without acute surgical intervention, is often fatal. Diagnosis requires pericardiocentesis; however, early consideration of the disease and its complications in the emergency department (ED) can be life-saving. Here, we present a case of an intravenous drug user who presented with altered mental status and a rectal temperature of 105.4°. While in the ED, the patient acutely decompensated. The ED physician performed bedside cardiac ultrasound that a showed pericardial effusion and right ventricle diastolic collapse concerning for cardiac tamponade. The patient underwent urgent pericardiocentesis which revealed 300 ml of purulent fluid. Both blood and pericardial cultures grew methicillin-sensitive Staphylococcus aureus. Despite a complicated hospital course, with appropriate antibiotic coverage and surgical intervention, the patient was discharged in good neurologic condition. This rare case of purulent pericarditis underscores the utility of bedside ultrasound in the ED and the complicated nature of altered mental status in intravenous drug users. Published by Elsevier Inc.
1. Case Purulent pericarditis with cardiac tamponade is a rare diagnosis that is not often considered by emergency physicians. However, prompt ED ultrasound may facilitate diagnosis and initiation of life-saving interventions. This is a case of an IVDA who presented with undifferentiated fever and altered mental status and was ultimately diagnosed with cardiac tamponade secondary to purulent pericarditis. A 33-yo male presented to the ED with altered mental status. He was found by EMS on a hot day “behaving erratically and inappropriately in his neighbor's yard”. Initial vital signs revealed an oral temperature of 98.1°, a rectal temperature of 105.4°, pulse of 150/min, respiratory rate of 46/min, blood pressure of 140/89 mm Hg, and SpO2 of 100% on room air. Physical exam was notable for poor dentition, track marks, and several erythematous macules on the soles of his feet (Fig. 1). The patient was oriented to self only. He appropriately followed simple commands, but could not answer complex questions and appeared extremely agitated. Work-up revealed leukocytosis of 28.4 K/μL with 42% bands, creatinine of 4.0 mg/dL, BUN of 66 mmol/L, and lactate of 4.2 mmol/L. CXR was unremarkable, and ECG showed sinus tachycardia. While in the ED, the patient's blood pressure acutely dropped to 80/50 mm Hg. A bedside ultrasound was performed that showed a large pericardial effusion with right ventricular diastolic collapse and concern for tamponade physiology (Fig. 2). The cardiologist, cardiothoracic surgeon, and intensivist were urgently contacted. The
patient was given vancomycin, ampicillin-sulbactam, and additional IV fluids and was started a norepinephrine infusion. The patient's blood pressure subsequently improved to 95/55 mm Hg. The remaining labs were significant for troponin of 8.58 μg/mL and urine drug screen positive for amphetamine and opiates. CT scans revealed a pericardial effusion and two areas of intracerebral hemorrhage within the occipital lobe (Figs. 3–4). Within 1 h of the ED ultrasound, the patient had an urgent pericardial window which revealed 300 ml of purulent fluid that grew methicillin-sensitive Staphylococcus aureus. The patient's vital signs immediately improved; however, given superimposed sepsis, he remained hemodynamically unstable. On hospital day one, transesophageal echocardiogram revealed persistent pericardial effusion, bicuspid aortic valve with a vegetation, and aortic insufficiency. The patient's course was complicated by the development of bilateral lower extremity gangrene due to septic emboli. Ultimately, he underwent bilateral lower extremity amputations and an aortic valve replacement. He was discharged on hospital day 23. 2. Discussion Purulent pericarditis is a rare condition in the antibiotic era. It is the most severe form of bacterial pericarditis and is characterized by gross pus within the pericardial sac. Bacterial invasion of the pericardium likely occurs through several different mechanisms: direct spread
http://dx.doi.org/10.1016/j.ajem.2017.04.068 0735-6757/Published by Elsevier Inc.
Please cite this article as: Gabler M, Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.04.068
2
M. Gabler / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Fig. 1. Erythematous lesions on sole of the patient's foot.
(e.g. pneumonia or pleural effusion), hematogenous seeding, spread from endocardial, myocardial, or subdiaphragmatic infections, and from trauma or surgery [1,2]. Mortality is as high as 40% with treatment and 100% when untreated [1]. It is more common in immunocompromised patients [3]. Many cases are associated with cardiac tamponade and sepsis, which both portend a poor prognosis and were present in this case [4]. Staphylococcus aureus remains the most common cause of purulent pericarditis (31%) followed by Streptococcus pneumoniae (22%) [5,6]. However, in recent years, the incidence of anaerobic organisms has increased, particularly in immunocompromised patients [7]. The clinical manifestations of purulent pericarditis vary significantly except for fever, which is present in practically all patients. Only about 50% of patients present with the classic findings of pericarditis [2]. Chest pain, pericardial friction rub, and physical exam findings consistent with tamponade physiology may all be seen. Most patients present with leukocytosis and an abnormal CXR and ECG. The most common radiographic abnormality is cardiomegaly followed by pulmonary infiltrates, pleural effusions, and mediastinal widening [5]. ECG most commonly shows changes consistent with acute pericarditis but may be normal in up to a third of patients [5,6]. Echocardiogram will reveal a pericardial effusion and may show findings consistent with cardiac tamponade. Although cardiac tamponade is a clinical diagnosis, certain finds on ultrasound suggest the diagnosis such as right ventricular diastolic collapse, right atrial collapse, respiratory inflow variation, and IVF plethora [8]. Bedside echocardiogram is extremely helpful in the diagnosis of purulent pericarditis especially when the diagnosis is not clear clinically. In this case, given the patient had superimposed sepsis, the pericardial effusion could have been
Fig. 2. Bedside echocardiogram performed in the ED demonstrating pericardial effusion and right ventricle collapse.
Fig. 3. Axial CT image demonstrating pericardial effusion.
missed. The ultrasound aided in the diagnosis allowing for timely intervention. The treatment of purulent pericarditis involves early administration broad-spectrum antibiotics and surgical intervention [4,9]. When endocarditis is suspected, penicillin G plus gentamicin is recommended and in patients with IVDA, vancomycin should be utilized [10]. Additionally, recent literature suggests intrapericardial fibrinolysis may be effective [11]. This rare case of purulent pericarditis underscores the complicated nature of altered mental status and fever in IVDA's and the utility of ED ultrasound. Bedside ultrasound aided in the diagnosis of purulent pericarditis and cardiac tamponade which expedited appropriate interventions. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2017.04.068.
Fig. 4. Axial CT image demonstrating two areas of intracerebral hemorrhage within the occipital lobe.
Please cite this article as: Gabler M, Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.04.068
M. Gabler / American Journal of Emergency Medicine xxx (2017) xxx–xxx
References [1] Keersmaekers T, Elshot SR, Sergeant PT. Primary bacterial pericarditis. Acta Cardiol 2002;57(5):387–9. [2] Sagrista-Sauleda J. Purulent pericarditis: review of a 20-year experience in a general hospital. J Am Coll Cardiol 1993;22:1661–5. [3] Cilloniz C, et al. Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series. J Bras Pneumol 2015 Jul-Aug;41(4):389–94. [4] Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnostic and management of pericardial diseases executive summary. The Task force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004;25:587–610. [5] Rubin RH, Moellering Jr RC. Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med 1975;59(1):68–78.
3
[6] Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent: an 86 year autopsy experience in 200 patients. Am J Med 1977;63:666–73. [7] Brook I, Frazier EH. Microbiology of acute purulent pericarditis. A 12-year experience in a military hospital. Arch Intern Med 1996;156(16):1857–60. [8] Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modalities, and management. Compr Ther 1995;21(7):378–85. [9] Leoncini G, Iurilli L, Queirolo A, et al. Primary and secondary purulent pericarditis in otherwise healthy adults. Interact Cardiovasc Thorac Surg 2006;5:652–4. [10] Goodman LJ. Purulent pericarditis. Curr Treat Options Cardiovasc Med 2000;2(4): 343–50. [11] Mayner J, Corral E, Manzano A, et al. Intrapericardial streptokinase fibrinolysis in the management of purulent pneumococcal pericarditis. Intensive Care Med 1999; 25(3):338–9.
Please cite this article as: Gabler M, Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.04.068
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound Mackenzie Gabler, MD Wright State University Department of Emergency Medicine, 3525 Southern Blvd, Kettering, OH 45429, United States
a r t i c l e
i n f o
Article history: Received 18 December 2016 Received in revised form 23 April 2017 Accepted 26 April 2017 Available online xxxx Keywords: Purulent pericarditis Cardiac tamponade Endocarditis Emergency department ultrasound
a b s t r a c t Purulent pericarditis is a rare but devastating disease process and even when treated, carries a poor prognosis. Cardiac tamponade is the most severe complication of purulent pericarditis and without acute surgical intervention, is often fatal. Diagnosis requires pericardiocentesis; however, early consideration of the disease and its complications in the emergency department (ED) can be life-saving. Here, we present a case of an intravenous drug user who presented with altered mental status and a rectal temperature of 105.4°. While in the ED, the patient acutely decompensated. The ED physician performed bedside cardiac ultrasound that a showed pericardial effusion and right ventricle diastolic collapse concerning for cardiac tamponade. The patient underwent urgent pericardiocentesis which revealed 300 ml of purulent fluid. Both blood and pericardial cultures grew methicillin-sensitive Staphylococcus aureus. Despite a complicated hospital course, with appropriate antibiotic coverage and surgical intervention, the patient was discharged in good neurologic condition. This rare case of purulent pericarditis underscores the utility of bedside ultrasound in the ED and the complicated nature of altered mental status in intravenous drug users. Published by Elsevier Inc.
1. Case Purulent pericarditis with cardiac tamponade is a rare diagnosis that is not often considered by emergency physicians. However, prompt ED ultrasound may facilitate diagnosis and initiation of life-saving interventions. This is a case of an IVDA who presented with undifferentiated fever and altered mental status and was ultimately diagnosed with cardiac tamponade secondary to purulent pericarditis. A 33-yo male presented to the ED with altered mental status. He was found by EMS on a hot day “behaving erratically and inappropriately in his neighbor's yard”. Initial vital signs revealed an oral temperature of 98.1°, a rectal temperature of 105.4°, pulse of 150/min, respiratory rate of 46/min, blood pressure of 140/89 mm Hg, and SpO2 of 100% on room air. Physical exam was notable for poor dentition, track marks, and several erythematous macules on the soles of his feet (Fig. 1). The patient was oriented to self only. He appropriately followed simple commands, but could not answer complex questions and appeared extremely agitated. Work-up revealed leukocytosis of 28.4 K/μL with 42% bands, creatinine of 4.0 mg/dL, BUN of 66 mmol/L, and lactate of 4.2 mmol/L. CXR was unremarkable, and ECG showed sinus tachycardia. While in the ED, the patient's blood pressure acutely dropped to 80/50 mm Hg. A bedside ultrasound was performed that showed a large pericardial effusion with right ventricular diastolic collapse and concern for tamponade physiology (Fig. 2). The cardiologist, cardiothoracic surgeon, and intensivist were urgently contacted. The
patient was given vancomycin, ampicillin-sulbactam, and additional IV fluids and was started a norepinephrine infusion. The patient's blood pressure subsequently improved to 95/55 mm Hg. The remaining labs were significant for troponin of 8.58 μg/mL and urine drug screen positive for amphetamine and opiates. CT scans revealed a pericardial effusion and two areas of intracerebral hemorrhage within the occipital lobe (Figs. 3–4). Within 1 h of the ED ultrasound, the patient had an urgent pericardial window which revealed 300 ml of purulent fluid that grew methicillin-sensitive Staphylococcus aureus. The patient's vital signs immediately improved; however, given superimposed sepsis, he remained hemodynamically unstable. On hospital day one, transesophageal echocardiogram revealed persistent pericardial effusion, bicuspid aortic valve with a vegetation, and aortic insufficiency. The patient's course was complicated by the development of bilateral lower extremity gangrene due to septic emboli. Ultimately, he underwent bilateral lower extremity amputations and an aortic valve replacement. He was discharged on hospital day 23. 2. Discussion Purulent pericarditis is a rare condition in the antibiotic era. It is the most severe form of bacterial pericarditis and is characterized by gross pus within the pericardial sac. Bacterial invasion of the pericardium likely occurs through several different mechanisms: direct spread
http://dx.doi.org/10.1016/j.ajem.2017.04.068 0735-6757/Published by Elsevier Inc.
Please cite this article as: Gabler M, Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.04.068
2
M. Gabler / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Fig. 1. Erythematous lesions on sole of the patient's foot.
(e.g. pneumonia or pleural effusion), hematogenous seeding, spread from endocardial, myocardial, or subdiaphragmatic infections, and from trauma or surgery [1,2]. Mortality is as high as 40% with treatment and 100% when untreated [1]. It is more common in immunocompromised patients [3]. Many cases are associated with cardiac tamponade and sepsis, which both portend a poor prognosis and were present in this case [4]. Staphylococcus aureus remains the most common cause of purulent pericarditis (31%) followed by Streptococcus pneumoniae (22%) [5,6]. However, in recent years, the incidence of anaerobic organisms has increased, particularly in immunocompromised patients [7]. The clinical manifestations of purulent pericarditis vary significantly except for fever, which is present in practically all patients. Only about 50% of patients present with the classic findings of pericarditis [2]. Chest pain, pericardial friction rub, and physical exam findings consistent with tamponade physiology may all be seen. Most patients present with leukocytosis and an abnormal CXR and ECG. The most common radiographic abnormality is cardiomegaly followed by pulmonary infiltrates, pleural effusions, and mediastinal widening [5]. ECG most commonly shows changes consistent with acute pericarditis but may be normal in up to a third of patients [5,6]. Echocardiogram will reveal a pericardial effusion and may show findings consistent with cardiac tamponade. Although cardiac tamponade is a clinical diagnosis, certain finds on ultrasound suggest the diagnosis such as right ventricular diastolic collapse, right atrial collapse, respiratory inflow variation, and IVF plethora [8]. Bedside echocardiogram is extremely helpful in the diagnosis of purulent pericarditis especially when the diagnosis is not clear clinically. In this case, given the patient had superimposed sepsis, the pericardial effusion could have been
Fig. 2. Bedside echocardiogram performed in the ED demonstrating pericardial effusion and right ventricle collapse.
Fig. 3. Axial CT image demonstrating pericardial effusion.
missed. The ultrasound aided in the diagnosis allowing for timely intervention. The treatment of purulent pericarditis involves early administration broad-spectrum antibiotics and surgical intervention [4,9]. When endocarditis is suspected, penicillin G plus gentamicin is recommended and in patients with IVDA, vancomycin should be utilized [10]. Additionally, recent literature suggests intrapericardial fibrinolysis may be effective [11]. This rare case of purulent pericarditis underscores the complicated nature of altered mental status and fever in IVDA's and the utility of ED ultrasound. Bedside ultrasound aided in the diagnosis of purulent pericarditis and cardiac tamponade which expedited appropriate interventions. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2017.04.068.
Fig. 4. Axial CT image demonstrating two areas of intracerebral hemorrhage within the occipital lobe.
Please cite this article as: Gabler M, Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.04.068
M. Gabler / American Journal of Emergency Medicine xxx (2017) xxx–xxx
References [1] Keersmaekers T, Elshot SR, Sergeant PT. Primary bacterial pericarditis. Acta Cardiol 2002;57(5):387–9. [2] Sagrista-Sauleda J. Purulent pericarditis: review of a 20-year experience in a general hospital. J Am Coll Cardiol 1993;22:1661–5. [3] Cilloniz C, et al. Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series. J Bras Pneumol 2015 Jul-Aug;41(4):389–94. [4] Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnostic and management of pericardial diseases executive summary. The Task force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004;25:587–610. [5] Rubin RH, Moellering Jr RC. Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med 1975;59(1):68–78.
3
[6] Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent: an 86 year autopsy experience in 200 patients. Am J Med 1977;63:666–73. [7] Brook I, Frazier EH. Microbiology of acute purulent pericarditis. A 12-year experience in a military hospital. Arch Intern Med 1996;156(16):1857–60. [8] Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modalities, and management. Compr Ther 1995;21(7):378–85. [9] Leoncini G, Iurilli L, Queirolo A, et al. Primary and secondary purulent pericarditis in otherwise healthy adults. Interact Cardiovasc Thorac Surg 2006;5:652–4. [10] Goodman LJ. Purulent pericarditis. Curr Treat Options Cardiovasc Med 2000;2(4): 343–50. [11] Mayner J, Corral E, Manzano A, et al. Intrapericardial streptokinase fibrinolysis in the management of purulent pneumococcal pericarditis. Intensive Care Med 1999; 25(3):338–9.
Please cite this article as: Gabler M, Cardiac tamponade secondary to purulent pericarditis diagnosed with the aid of emergency department ultrasound, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.04.068