Purulent pericardial effusion

Pericardial

Purulent

Effusion

MEYER TEXON, M.D. NEW

M

ASSIVE purulent fusion

is of sufficient

academic

following

interest

A forty-six-year on October

and the

9,1944,

days’ duration. alcoholism

Medical

to 900,000

The

history

sufficient

examination

fourteenth

venously

revealed

teenth

excessive

A few crepitant

pulmonary

r%les were

films (Fig.

fingerbreadths

the

costal

sistent

The body hair was sparse. A few facial telangec-

teenth

tases were noted.

about

There upon

red blood Cm.,

The nail beds were cyanosed.

was no jaundice. admission count

The

included:

laboratory

4.7 million,

14.5

lymphocytes.

Urinalysis

1.030, acid, albumin occasional

on the

evidence solidation. size and

day

of admission

of any pulmonary

revealed

infiltration

The heart is within normal configuration.”

with

The

“no

limits of

admitting

nosis was right lower lobe pneumonia, chronic alcoholism with liver cirrhosis

JOURNAL

OF

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gallop

changes

effusion.

con-

On

the thir-

paracentesis

yielded

fluid. On the

to be good with no pericardial

or murmurs about

audible. 140180

tapping.

appeared

The

blood

on the day of

On the twentieth

blowing

murmur

at the apex. On the thirteenth

day the

patient

continued he

to

claim

appeared

increasing but

a persistent

day

systolic

persisted

pallor.

weaker The

no pericardial The

“improvement”

circulation

and apical

rub

the

skin

murmur

or petechiae

time was normal

(18 seconds) on the seventeenth day. A transfusion, 500 cc. of whole blood, was given on the thirty-first day, the red blood count having dropped to 3.65 million and the hemoglobin to 71 per cent, 10.2 Gm. On the thirty-third day

tered during the first four days had no appreciable effect on the sustained fever. Penicillin, AMERICAN

days showed

sixteenth

day large doses of aspirin were given

were noted.

avitaminosis. From Figure 1 depicting the course, it may be noted that 22 Gm. of sulfadiazine adminis-

shadow.

on the

The signs

showed

and and

3)

The heart

although

diag-

eight-

in the lungs seemed to clear entirely.

there

or con-

(Fig.

pericardial

the pericardial

casts. An x-ray of the

he chest

fifteenth,

15 cc. of a serosanguineous

pressure remained

revealed specific gravity

but objectively

in an effort to lower the temperature.

rub,

and 4 per cent

2 plus, sugar negative,

fine granular

day

ap-

the patient

days showed progres-

pericardial

sounds continued

100 per cent, white blood count 21,000 with

96 per cent polymorphonuclears,

chest

103’F.,

hemoglobin

with

fourteenth

data

temperature

On

shadow

in the size of the heart

and twenty-second

No

The skin was hot and dry.

better

2) on the eleventh,

Electrocardiograms

to two

margin.

thereafter.

Clinically,

and twenty-fourth

sive increase

pressure was 122/80,pulse

below

spleen was palpable.

chloride

acutely ill and drowsy. Repeated

eenth,

size and rhythm

The liver was enlarged

daily

but the heart

to be feeling

bra1 area.

sounds,

change”

peared slightly enlarged.

disclosed

heard over the right lower lobe in the paraverteBlood

cent intra-

the fifth day the second chest x-ray showed “no

with

meats and greens. The

appeared

100 per minute.

of 5 per

on the fourth day. Thiamine

day and repeated

claimed

were normal.

cc.

third and fourth day, then resumed on the four-

upon admission

heart

3,000

of fever, diffuse

herpes of the lips and a furry tongue having red,

The

day;

to a total

at the same time until

and chills of five

atrophic

margins.

units. Sulfadiazine

glucose in normal saline was administered

Ward

for about fifteen years, together

a diet lacking

Oxford

in doses of 100 mg. was given by vein on the

complaining cough

units every three hours, was then given

of 76 Gm. was continued

old white male was admitted Hospital

YORK

for the next nine days, the total dose amounting

the

non-productive

physical

clinical

to warrant

NEW

20,000

ef-

case report:

to the Knickerbocker aches,

pericardial

YORK,

577

578

Pericardial Effusion-Texan

.

Ii I

loo

I

I

I

FIG. 1. Chart depicting the course of the disease. the patient expired having become more cyanotic muffled,

indistinct

Additional Kline

with a rapid,

300,000

The

negative

pericardial

the posterior

above the apex, there

myocardium

(all lymphocytes).

staphylococcus

Culture

aureus.

from the pericardial

hemolytic

streptococci,

and pneumococci

produced

coli

performed

revealed

the

by Dr. Joseph

following:

The

heart

Balis

approached through an abdominal incision so that the shape and size are not discernible. The pericardial seropurulent

sac is markedly

parboiled

pale,

cardial

glistening

distended with turbid

fluid of moderate

viscosity, measur-

ing 1,500 cc. in volume.

In two places the two

layers of the pericardium

are firmly and densely

adherent. One of these is at the apex and adjacent left lateral border over an area 5 by

save for the aortic,

at the point thickened There

patent,

cular

fusion of all

in places measuring

up to 1 cm.

and their

The

surface

tween

the

slightly

on any soft,

pink,

of the commissural

right

and

surrounding

are inseparably attached and represent an old process. Elsewhere the pericardial sac is filled with the above described fluid. The two internal surfaces of the pericardium are covered with a mass of shaggy, fibrinous, tannish-brown, fri-

arteries

are everywhere

widely

patent.

left

or underlying

cusps. The foramen are obliterated.

rolled.

of the

cusps.

smooth,

7 by 5 by 5 mm. on the ventri-

6 cm., the other layer over the anterior septum occupied an area 3 by 1.5 cm. These adhesions

normal.

cusps are slightly

free edges

is a single,

fleshy vegetation

and all valves,

a marked

of fusion.

there

The endo-

of the heart are

are free from gross change.

are no verrucae

Instead

in

and measures

and free from change.

The aortic valve presents its commissures

The

of the left ventricle

surface of the chambers

pale, smooth,

above the

tannish-grey

in appearance,

All orifices are normally

VII.

necropsy

is flabby,

wall of

the epicardium.

and 2 to 3 mm. in the right ventricle.

produced

bacillus

color,

and beneath

9 mm. at its thickest portion

Postmortem

effusion

hemolytic

type

The

directly

is a 1 by 1 cm. cheesy abscess directly

red blood cells per c. mm., 3,400 white

hemolytic

linger

and

up to 1 cm. in thick-

the left ventricle, myocardium

smear revealed no organisms.

The

Kahn

fluid

measuring

ness. In one focus along

revealed

blood cells per c. mm.,

cultures

able adhesions

pulse and

heart sounds.

data included

tests.

progressively

thready

There

ulceration

beis no

of

the

ovale and ductus arteriosus

The The

junction

cusps.

coronary smooth, vena

ostia

and

their

glistening

and

cavae

are

grossly

Pericardial

Effusion-Texan

E

D

FIG. 2.

Microscopically,

to

A

F,

the

fibers

swollen by the moderately tous

degenerative

are

somewhat

severe parenchyma-

changes.

The

surface is fibrously thickened a thick coat of inflammatory

epicardial

and covered with reaction, the base

of which is already

densely

fibrous

larized (non-specific

chronic

granulation

The uppermost of an

acute

F

films show progressive increase in the size of heart shadow.

x-ray

and vascutissue).

layers of the coat are composed fibrinopurulent

exudate.

cells and phagocytosed

blood pigment

in the deeper fibrosed

portion

Plasma are noted

of the epicardial

There

is no evidence

farction

or hemorrhage

lung. There

is marked

of consolidation, in any portion

distention

inof the

and engorgement

of the central veins and sinusoids of the liver with early fatty metamorphosis of hepatic

of the peripheral

zone

cells. Grossly the liver weighed

2,260

Gm. The external. and brownish resistance

surface is smooth,

to present

reddish-brown

glistening

tan. The organ cuts with normal areas

a nutmeg

appearance

of

surrounded

by paler

tan

coat. No evidence of tuberculosis is seen. The grossly described cheesy abscess in the subperi-

areas representing passive congestion. The remainder of the organs revealed no unusual

cardial zone represents a purulent non-specific abscess showing early walling off by granulation tissue in which there are a few non-specific

changes. The final diagnosis purulent pericardial

multinucleated

rheumatic

AMERICAN

giant cells.

,,O”RNAL

OF

MEDICINE

commissural

was massive serofibrinoeffusion; congenital or fusion

of

the

aortic

580

Pericardial Effusion-Texan

FIG. 3.

A

to

H,

electrocardiograms

show changes

cusps, with superimposed recent vegetation (thrombotic, non-bacterial, vegetative endocarditis); and chronic passive congestion of the liver. COMMENTS

The diagnosis of pneumonia upon mission was justified clinically although

adnot

visualized by x-ray. This may have been due to a retrocardiac position of the process. The involvement of the pericardium must be presumed to have occurred tiguity. The therapy might have penicillin cardial

instilled sac.

The

directly incidental

into

by conincluded the

finding

periat

consistent

necropsy

with pericardial

of a rheumatic

effusion.

heart

with aortic

valvular involvement and vegetation again points out the frequency with which this occurs without obvious clinical signs or symptoms. It is believed that the cause of death was toxemia from the massive purulent pericardial effusion. Also, the patient, an alcoholic, did not resist the infection normal constitutional powers.

with

SUMMARY

A fatal

case of purulent

pericardial

ef-

fusion in which the patient was treated with sulfadiazine and penicillin is presented.

AMERICAN

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