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Surgical treatment of purulent pericarditis in children
J
THORAC CARDIOVASC SURG
85:527-531, 1983
Surgical treatment of purulent pericarditis in children Since 1971 we have seen 15 children with the diagnosis of purulent pericarditis. The causative organism was Hemophilus influenzae in seven, Staphylococcus aureus in three, and five were due to other organisms. In one child the diagnosis was unsuspected until autopsy. The other 14 patients were all treated with intravenous antibiotics to which the organism was sensitive. One child had an immediate pericardiectomy because of tamponade. The other 13 patients had pericardiocentesis for diagnosis and initial therapy. Pericardiocentesis alone resulted in recovery offour patients and failed in nine, including all seven patients with H. influenzae. These nine had recurrent tamponade or a persistent picture of sepsis that was unresponsive to repeated pericardiocenteses and necessitated operative intervention. The procedure used was subxiphoid tube drainage in two patients. One recovered and the other required further operation. The remaining seven patients were treated with pericardiectomy. All pericardiectomy patients recovered without complications or recurrent symptoms. Survivors are asymptomatic with no evidence of pericardial constriction. We recommend immediate pericardiocentesis for diagnosis and initial therapv. Early pericardiectomy should be performed if the causative organism is H. influenzae, if tamponade occurs after initial pericardiocentesis, or iffever persists despite appropriate antibiotics.
Richard J. Morgan, M.D., Larry W. Stephenson, M.D., Paul K. Woolf, M.D., Richard N. Edie, M.D., and L. Henry Edmunds, Jr., M.D., Philadelphia, Pa.
T
he role of surgery in treatment of purulent pericarditis in children has been controversial. If untreated, the disease is usually fatal.' , 2 A combination of antibiotic therapy and pericardial drainage has brought the mortality down to 22%, as reported in a recent review of the literature." However, the type of pericardial drainage required and the risk of subsequent constrictive pericarditis if the pericardium is not removed remain unclear. This study reviews our experience with purulent pericarditis in children and compares it to previously reported cases in an attempt to devise a logical treatment plan. Material and methods
Fifteen patients with acute bacterial pericarditis were seen at the Children's Hospital of Philadelphia between From the Division of Cardiothoracic Surgery and Pediatric Cardiology, The Children's Hospital of Philadelphia, and from the School of Medicine of the University of Pennsylvania, Philadelphia, Pa. Received for publication April 12, 1982. Accepted for publication May 26, 1982. Address for reprints: Larry W. Stephenson, M.D., Children's Hospital of Philadelphia, 34th 51. and Civic Center Blvd., Philadelphia, Pa. 19104.
1971 and May, 1981. Each of these children had either gross or microscopic evidence of pus in the pericardium. The causative organism was cultured from the pericardial fluid in seven patients. It was identified by countercurrent immunoelectrophoresis of the pericardial fluid in one. In the other seven patients the pericardial aspirate showed gross pus but was negative on culture. However, the causative organism was presumed to be that grown from the blood of four patients, from both the cerebrospinal fluid and the synovial fluid in one patient, and from the nasopharynx in one patient whose pericardial Gram stain was consistent with Hemophilus infiuenzae. The causative organism was never cultured in one patient who had gram-positive cocci in the Gram stain of the pericardial fluid obtained at autopsy. Results Table I summarizes the clinical presentations of these 15 children. Their ages ranged from 7 days to 6 years. Fourteen were 4 years of age or less. All presented with a febrile illness of short duration, ranging from I to 9 days. One patient was admitted with otitis media and septic shock after 24 hours of intravenous antibiotics at another hospital. He died less than 24 hours after admission. Autopsy revealed an unsus527
The Journal of Thoracic and Cardiovascular Surgery
528 Morgan et al.
Table I. Clinical presentation Case No.
Organism
Duration of illness (days)
Initial presentation
Fever, tachypnea respiratory distress Fever, abdominal pain, vomiting Fever, abdominal pain, vomiting Fever, vomiting Tamponade, respiratory distress Fever, vomiting, disorientation, shock Fever, knee pain, respiratory distress Respiratory distress
30 mo
H. infiuenzae type B
3
2
3 yr
H. influenzae type B
2
3
3 yr
H. infiuenzae type B
7
4 5
9 mo 3 yr
H. influenzae type B H. infiuenzae type B
3 3
6
4 yr
H. infiuenzae type B
4
7
limo
H. influenzae type D
7
8
14 mo
S. aureus
4
12 13
21 3 9 19 6
S. aureus S. aureus Streptococcus Group A Pneumococcus Meningococcus
7 4 2 7 9
14 15
7 days 19 mo
Klebsiella Gram-positive diplococci
I ?
9 10 II
mo yr mo mo
pected purulent pericarditis. The other 14 all complained of respiratory distress, anorexia, or abdominal discomfort: Eight patients had a concurrent clinically significant infection at another site, and three children complained primarily of symptoms related to the associated infection. None of these children was found to have an immune deficiency and none is known to have been hospitalized with a subsequent infection. Table II summarizes the bacteriologic findings. The most common causative organism was H. irfluenzae, which was documented to be the cause in six cases and presumed to be the cause in one other child. Six of these were H. infiuenzae type B and one was H. inftuenzae type D. Three cases were caused by Staphylococcus aureus and one each by Group A streptococcus, Streptococcus pneumoniae, Neisseria meningitis, and Klebsiella. In one case found at autopsy there was pus in the pericardium that showed gram-positive diplococci on Gram stain. The causative organism was never cultured, probably because the child has been treated with antibiotics. The causative organism was cultured from the pericardium of seven patients. One other patient had a countercurrent immunoelectrophoresis positive for H. influenzae. Nine patients had positive blood cultures, and the organism was cultured from at least one other
Fever, anorexia Fever, anorexia Fever, respiratory distress Fever, anorexia, lethargy Fever, meningitis, abdominal pain, vomiting Fever, respiratory distress Otitis, sepsis, renal failure, adrenal necrosis, shock
Associated sites of infection
Pneumonia None Left knee Submandibular abscess, bilateral hip arthritis Scalp, buttock abscess Femoral osteomyelitis
Meningitis, arthritis Pneumonia Otitis
distant site in eight patients. Two other patients also had evidence of pneumonia on chest x-ray film but no organism grew from the sputum. The treatment received by these patients is summarized in Table III. All 15 children were treated with antibiotics. In one patient, who died presumably of sepsis, the diagnosis was not suspected until autopsy. In the 14 survivors, the duration of antibiotic treatment ranged from 2 to 6 weeks. Pericardial decompression of some type was provided in all 14 survivors, but not in the child who died. In one survivor, the diagnosis was made on clinical grounds and a pericardiectomy was performed without prior diagnostic pericardiocentesis. The other 13 patients had one or more pericardiocenteses. Four patients had a simple needle aspiration. Two of these recovered and two required repeat pericardiocentesis followed by operative decompression of the pericardium. In nine patients a drainage catheter was left in the pericardium at the time of the initial pericardiocentesis. Two of these children recovered and seven required an operation. In no instance was repeated pericardiocentesis successful in avoiding an operation. Operations were performed in 10 patients. Two children underwent placement of a subxiphoid tube. One recovered and the other required reexploration and
Volume 85 Number 4 April,1983
Purulent pericarditis in children
5 29
Table II. Diagnostic criteria Case No. I
2 3
4
5 6 7
8 9 10 II
12 13 14
15
Organism
Gross diagnosis made by:
Pericardial fluid culture
H. infiuenzae type B H. influenzae type B H. influenzae type B H. influenzae type B H. influenzae type B H. infiuenzae type B H. infiuenzae type D S. aureus S. aureus S. aureus Streptococcus Group A Pneumococcus Meningococcus Klebsiella Gram-positive diplococci
Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Operation Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Autopsy
+
Blood cultures
Other
+
+
-(CIE+ )
+ + +
Nasopharynx Nasopharynx
+
Knee + Submandibular abscess Scalp, abscesses
+
+ + +
+ +
+
+ +
Throat
+
+
CSF, left hip Sputum
+
+
+
Legend: ClE, Countercurrent immunoelectrophoresis; CSF, Cerebrospinal fluid.
Table III. Treatment Case No. I
2 3 4 5
6 7
8 9 10 II
12 13 14 15
Organism
Major antibiotic
H. influenzae type B H. influenzae type B H. infiuenzae type B H. influenzae type B H. infiuenzae type B H. infiuenzae type B H. influenzae type D S. aureus S. aureus S. aureus Streptococcus Group A
Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Cephalothin Nafc illin Nafcillin Penicillin G
Pneumococcus Meningococcus Klebsiella Gram-positive cocci
Penicillin G Penicillin G Cephalothin, gentamicin, PON" Ampicillin
Duration of antibiotics (wk)
Initial pericardial drainage
No. of pericardiocenteses
PC PC PC PC P PC PC PC PC OP P
2
4 5
3 5
3 4
3 3 4
6 2 4 3
2 Until death
PC P P None
I I 4
2 I I I I 0 3 I I I
0
Operation
Results
AlP AlP AlP AIP TP AlP Tube
Good Good Good Good Good Good Good Good Good Good Needed reexploration Good Good Good Died
AlP Tube AlP
Legend: P, Needle pericardiocenteses. PC, Pericardiocentesiscatheter drainage. OP, Immediate operation. AlP, Anterior interphrenic pericardiectomy. TP, Total
pericardiectomy. Tube, Subxiphoid tube pericardiectomy.
pericardial window for adequate drainage. Anterior interphrenic pericardiectomies were performed in seven patients and a total pericardiectomy in one. A median sternotomy was used in five patients who had anterior interphrenic pericardiectomies and in the patient who had a total pericardiectomy. A left anterior thoracotomy was used in two of the patients who had anterior interphrenic pericardiectomies. No wound complications were noted with either incision. All of these patients recovered uneventfully with no instance of recurrent pericardial sepsis or tamponade and with no
significant complications. The length of hospitalization for these children was determined by the length of intravenous antibiotic therapy elected postoperatively. The 14 survivors have been followed for from 4 months to 13 years. None has had recurrent purulent pericarditis. All are in New York Heart Association Class I, and none is receiving cardiac medication. Discussion
This series demonstrates that purulent pericarditis, once a fatal disease, can now be treated successfully if
The Journal of
530 Morgan et al.
an appropriate management plan is followed. All of the patients in whom the diagnosis was made premortem survived with no complications on short- or long-term follow-up. General agreement exists that the treatment of purulent pericarditis requires both pericardial drainage and appropriate antibiotic therapy. The indications for operation and the preferable form of pericardial drainage have not been defined. The mortality for untreated cases approaches 100%.1, 2, 4, 5 The fact that antibiotic therapy alone is not sufficient is demonstrated by the death of the one patient in our series, who did not have pericardial drainage, and by the 82% mortality reported for antibiotic therapy alone in a previous report. 3 Pericardiocentesis can provide adequate drainage if the infected pericardial fluid is thin enough to flow through a needle or through a percutaneously placed drainage catheter. This was successful in four of the 12 cases in this series in which it was attempted. Patients who had recurrent pericardial sepsis or tamponade were not helped by repeated pericardiocenteses. Benzig and Kaplan" confirmed this finding. They reported that only one of six patients treated with multiple pericardiocenteses recovered, and the other five required operations. The reason that pericardiocentesis fails is probably that the pericardial pus is either loculated or too thick to flow through a needle. H. irfiuenzae usually produces such pus. All seven of the patients in our series with H. infiuenzae required operative intervention, as did all five patients reported by Cosgrove, Echeverria, and Sade" and all nine of the patients reported by Cheatham and associates. 7 Pericardiostomy can provide successful drainage and is sometimes recommended as the treatment of choice.?"!" However, pericardiostomy often provides inadequate drainage, as it did in one of our two patients in whom it was attempted. This is similar to the findings of Carneron.t" who reported that two of 10 patients with Staphylococcus aureus pericarditis treated with antibiotics and tube drainage died and three required at least one reexploration. Cameron believed that pericardiectomy was contraindicated because it was a "potential cause of bacteremia. " This complication was not seen in our patients who had pericardiectomy or in other series. 11 - 13 All of our pericardiectomy patients recovered without complications and none had subsequent pericardial sepsis or tamponade. A theoretical advantage of pericardiectomy over pericardial drainage is the prevention of late constrictive pericarditis. The incidence of this complication is not clear, but at least 20 cases have been reported. 14, 15
Thoracic and Cardiovascular Surgery
Ten were caused by Staphylococcus aureus, five by H. irfluenzae, three by meningococcus, and two by Pastuerella tularensis. The constriction typically occurs within 8 weeks of the acute illness and progresses rapidly. Constriction has occurred after treatment with antibiotics alone.'" and also after apparently adequate treatment with antibiotics and pericardiocentesis'" or pericardiostomy.l" None of our patients thus far has evidence of constriction. We conclude from the present series and from a literature review that immediate diagnostic and therapeutic pericardiocentesis should be performed for any child suspected of having purulent pericarditis. Early pericardiectomy should be performed if the causative organism is H. infiuenzae . In other patients, pericardiectomy should be performed immediately if tamponade occurs after initial pericardiectomy or if fever persists despite appropriate antibiotic therapy. We do not recommend multiple pericardiocenteses or tube drainage. REFERENCES
2 3
4
5 6
7
8
9 10 II
12 13
Okoroma EO, Perry LW, Scott LP III: Acute bacterial pericarditis in children. Report of 25 cases. Am Heart 1 90:709-713, 1975 Benzig G III, Kaplan S: Purulent pericarditis. Am 1 Dis Child 106:289-294, 1963 Feldman W: Bacterial etiology and mortality of purulent pericarditis in pediatric patients. Am 1 Dis Child 133: 641-644, 1979 Keith 1D, Rowe RD, Vlad P: Heart Disease in Infancy and Childhood, ed 3, New York, 1978, Macmillan Publishing Co., Inc. pp 250-251 Kauffman CA, Watanakunakom S, Phair 1P: Purulent pneumococcal pericarditis. Am 1 Med 54:743-749,1973 Cosgrove DM, Echeverria P, Sade RM: The management of Hemophilus irfiuenzae, Type B, pericarditis. Ann Thorac Surg 21:281-283, 1976 Cheatham JE 1r, Grantham RN, Peyton MD, Thompson WM, Luckstead EF, Razook 1D, Elkins RC: Hemophilus irfluenzae purulent pericarditis in children. 1 THORAC CARDIOVASC SURG 79:933-936, 1980 Wyler F, Knusli D, Rutishauser M, Stocker F, Weber 1, Real F: Pericarditis purulenta in children. Helv Paediatr Acta 32:135-140, 1977 Nghiem DD, Pate 1W: Purulent pericarditis in South Vietnam. South Med 1 67:1306-1307, 1974 Cameron EW1: Surgical management of staphylococcal pericarditis. Thorax 30:678-681, 1975 Echeverria P, Smith EWP, Ingram D, Sade RM, Gardner P: Hemophilus irfiuenzae b pericarditis in children. Pediatrics 56:808-818, 1975 Das PB, Ray D: Surgical management of pyogenic pericarditis. Int Surg 61:483-485, 1976 Sinclair MC: Acute pyogenic pericarditis. The role of pericardiectomy. E Afr Med 1 55: 136-142, 1978
Volume 85 Number 4
April,1983
14 Strauss AW, Santa-Maria M, Goldring D: Constrictive pericarditis in children. Am J Dis Child 129:822-826. 1975 15 Weir EK, Joffe HS: Purulent pericarditis in children. An analysis of 28 cases. Thorax 32:438-443, 1977 16 Noonan JA. Walters LR, Bryant L. Toomey FS: Acute constrictive pericarditis following Hemophilus infiuenzae infection. Circulation 40:Suppl 3: 155. 1969 17 Caird R, Conway N. McMillan IKR: Purulent pericarditis followed by early constriction in young children. Br Heart J 35:201-203. 1973
Treatment of purulent pericarditis-a comment There are two considerations in treating patients with purulent pericarditis: (I) resolution of the acute infection and (2) prevention of constrictive pericarditis. Prompt and complete evacuation of the infected pericardial space and use of antibiotics are necessary to eliminate the acute infectious process. Morgan and his colleagues demonstrate quite nicely that needle or small-bore catheter pericardiocentesis and drainage are inadequate to evacuate the pericardial space effectively in the majority of patients with purulent pericarditis. However, the safest and most effective method of surgical drainage of the pericardial space remains to be defined. While the authors suggest that pericardiectomy should be performed in all cases of H. injluen::.ae pericarditis, it is possible that subxiphoid surgical drainage with a large-bore pericardiostomy tube would have been as effective as pericardiectomy if done shortly after diagnosis. The authors recommend pericardiectomy for patients with purulent pericarditis caused by an organism other than H. infiuenzae only if cardiac tamponade occurs or if fever persists despite appropriate antibiotic therapy. Some investigators, however, recommend early surgical pericardial drainage in all cases of purulent pericarditis regardless of the causative organism. It is vital that appropriate antibiotic therapy be utilized. Appropriate antibiotic therapy includes the correct antibiotic (confirmed by in vitro sensitivity testing), the correct dose (confirmed by serum antibiotic assay), the correct route of administration (intravenous), and the correct time (begun immediately upon diagnosis). The relationship between the technique of pericardial
Purulent pericarditis in children
531
drainage and subsequent development of constrictive pericarditis is unknown. It is estimated that constrictive pericarditis will develop in 4% to 16% of patients who have had purulent pericarditis. I. 2 As Morgan and associates indicate, the occurrence of constrictive pericarditis will be rare following total pericardiectomy. However, if early subxiphoid surgical drainage of the pericardium with a large-bore pericardiostomy tube is as effective as pericardiectomy in preventing constrictive pericarditis, many patients could be spared the more substantial operative procedure of total pericardiectomy. David J. Driscoll, M.D. K. Hable Rhodes, M.D. Rochester, Minn. REFERENCES Boyle J, Pearce M, Guze L: Purulent pericarditis. Review of the literature and report of II cases. Medicine 41: 119144, 1961 2 Van Reken D, Strauss A, Hernandez A, Feigin R: Infectious pericarditis in children. J Pediatr 85: 165-169, 1974
Authors' response We certainly agree with most of the points made by Drs. Driscoll and Hable Rhodes in regard to our paper on purulent pericarditis. They raise the question as to whether subxiphoid surgical drainage with a large-bore tube placed 'in the pericardium might not be preferable to pericardiectomy. We believe that more data (a larger number of patients) are needed to settle this issue. In our experience the consistency of the purulent material in those patients with H. influenzae has been similar to that of scrambled eggs. The purulent material is not drained from the pericardium but actually scooped out at operation. Sometimes, friable lumps of the material have to be dissected off the heart and from around the great vessels. It seems unlikely that tube drainage would be successful in these cases. Richard J. Morgan, M.D. Larry W. Stephenson, M.D. Paul K. Woo({, M.D. Richard N. Edie, M.D. L. Henry Edmunds, Jr., M.D. Philadelphia, Pa.
THORAC CARDIOVASC SURG
85:527-531, 1983
Surgical treatment of purulent pericarditis in children Since 1971 we have seen 15 children with the diagnosis of purulent pericarditis. The causative organism was Hemophilus influenzae in seven, Staphylococcus aureus in three, and five were due to other organisms. In one child the diagnosis was unsuspected until autopsy. The other 14 patients were all treated with intravenous antibiotics to which the organism was sensitive. One child had an immediate pericardiectomy because of tamponade. The other 13 patients had pericardiocentesis for diagnosis and initial therapy. Pericardiocentesis alone resulted in recovery offour patients and failed in nine, including all seven patients with H. influenzae. These nine had recurrent tamponade or a persistent picture of sepsis that was unresponsive to repeated pericardiocenteses and necessitated operative intervention. The procedure used was subxiphoid tube drainage in two patients. One recovered and the other required further operation. The remaining seven patients were treated with pericardiectomy. All pericardiectomy patients recovered without complications or recurrent symptoms. Survivors are asymptomatic with no evidence of pericardial constriction. We recommend immediate pericardiocentesis for diagnosis and initial therapv. Early pericardiectomy should be performed if the causative organism is H. influenzae, if tamponade occurs after initial pericardiocentesis, or iffever persists despite appropriate antibiotics.
Richard J. Morgan, M.D., Larry W. Stephenson, M.D., Paul K. Woolf, M.D., Richard N. Edie, M.D., and L. Henry Edmunds, Jr., M.D., Philadelphia, Pa.
T
he role of surgery in treatment of purulent pericarditis in children has been controversial. If untreated, the disease is usually fatal.' , 2 A combination of antibiotic therapy and pericardial drainage has brought the mortality down to 22%, as reported in a recent review of the literature." However, the type of pericardial drainage required and the risk of subsequent constrictive pericarditis if the pericardium is not removed remain unclear. This study reviews our experience with purulent pericarditis in children and compares it to previously reported cases in an attempt to devise a logical treatment plan. Material and methods
Fifteen patients with acute bacterial pericarditis were seen at the Children's Hospital of Philadelphia between From the Division of Cardiothoracic Surgery and Pediatric Cardiology, The Children's Hospital of Philadelphia, and from the School of Medicine of the University of Pennsylvania, Philadelphia, Pa. Received for publication April 12, 1982. Accepted for publication May 26, 1982. Address for reprints: Larry W. Stephenson, M.D., Children's Hospital of Philadelphia, 34th 51. and Civic Center Blvd., Philadelphia, Pa. 19104.
1971 and May, 1981. Each of these children had either gross or microscopic evidence of pus in the pericardium. The causative organism was cultured from the pericardial fluid in seven patients. It was identified by countercurrent immunoelectrophoresis of the pericardial fluid in one. In the other seven patients the pericardial aspirate showed gross pus but was negative on culture. However, the causative organism was presumed to be that grown from the blood of four patients, from both the cerebrospinal fluid and the synovial fluid in one patient, and from the nasopharynx in one patient whose pericardial Gram stain was consistent with Hemophilus infiuenzae. The causative organism was never cultured in one patient who had gram-positive cocci in the Gram stain of the pericardial fluid obtained at autopsy. Results Table I summarizes the clinical presentations of these 15 children. Their ages ranged from 7 days to 6 years. Fourteen were 4 years of age or less. All presented with a febrile illness of short duration, ranging from I to 9 days. One patient was admitted with otitis media and septic shock after 24 hours of intravenous antibiotics at another hospital. He died less than 24 hours after admission. Autopsy revealed an unsus527
The Journal of Thoracic and Cardiovascular Surgery
528 Morgan et al.
Table I. Clinical presentation Case No.
Organism
Duration of illness (days)
Initial presentation
Fever, tachypnea respiratory distress Fever, abdominal pain, vomiting Fever, abdominal pain, vomiting Fever, vomiting Tamponade, respiratory distress Fever, vomiting, disorientation, shock Fever, knee pain, respiratory distress Respiratory distress
30 mo
H. infiuenzae type B
3
2
3 yr
H. influenzae type B
2
3
3 yr
H. infiuenzae type B
7
4 5
9 mo 3 yr
H. influenzae type B H. infiuenzae type B
3 3
6
4 yr
H. infiuenzae type B
4
7
limo
H. influenzae type D
7
8
14 mo
S. aureus
4
12 13
21 3 9 19 6
S. aureus S. aureus Streptococcus Group A Pneumococcus Meningococcus
7 4 2 7 9
14 15
7 days 19 mo
Klebsiella Gram-positive diplococci
I ?
9 10 II
mo yr mo mo
pected purulent pericarditis. The other 14 all complained of respiratory distress, anorexia, or abdominal discomfort: Eight patients had a concurrent clinically significant infection at another site, and three children complained primarily of symptoms related to the associated infection. None of these children was found to have an immune deficiency and none is known to have been hospitalized with a subsequent infection. Table II summarizes the bacteriologic findings. The most common causative organism was H. irfluenzae, which was documented to be the cause in six cases and presumed to be the cause in one other child. Six of these were H. infiuenzae type B and one was H. inftuenzae type D. Three cases were caused by Staphylococcus aureus and one each by Group A streptococcus, Streptococcus pneumoniae, Neisseria meningitis, and Klebsiella. In one case found at autopsy there was pus in the pericardium that showed gram-positive diplococci on Gram stain. The causative organism was never cultured, probably because the child has been treated with antibiotics. The causative organism was cultured from the pericardium of seven patients. One other patient had a countercurrent immunoelectrophoresis positive for H. influenzae. Nine patients had positive blood cultures, and the organism was cultured from at least one other
Fever, anorexia Fever, anorexia Fever, respiratory distress Fever, anorexia, lethargy Fever, meningitis, abdominal pain, vomiting Fever, respiratory distress Otitis, sepsis, renal failure, adrenal necrosis, shock
Associated sites of infection
Pneumonia None Left knee Submandibular abscess, bilateral hip arthritis Scalp, buttock abscess Femoral osteomyelitis
Meningitis, arthritis Pneumonia Otitis
distant site in eight patients. Two other patients also had evidence of pneumonia on chest x-ray film but no organism grew from the sputum. The treatment received by these patients is summarized in Table III. All 15 children were treated with antibiotics. In one patient, who died presumably of sepsis, the diagnosis was not suspected until autopsy. In the 14 survivors, the duration of antibiotic treatment ranged from 2 to 6 weeks. Pericardial decompression of some type was provided in all 14 survivors, but not in the child who died. In one survivor, the diagnosis was made on clinical grounds and a pericardiectomy was performed without prior diagnostic pericardiocentesis. The other 13 patients had one or more pericardiocenteses. Four patients had a simple needle aspiration. Two of these recovered and two required repeat pericardiocentesis followed by operative decompression of the pericardium. In nine patients a drainage catheter was left in the pericardium at the time of the initial pericardiocentesis. Two of these children recovered and seven required an operation. In no instance was repeated pericardiocentesis successful in avoiding an operation. Operations were performed in 10 patients. Two children underwent placement of a subxiphoid tube. One recovered and the other required reexploration and
Volume 85 Number 4 April,1983
Purulent pericarditis in children
5 29
Table II. Diagnostic criteria Case No. I
2 3
4
5 6 7
8 9 10 II
12 13 14
15
Organism
Gross diagnosis made by:
Pericardial fluid culture
H. infiuenzae type B H. influenzae type B H. influenzae type B H. influenzae type B H. influenzae type B H. infiuenzae type B H. infiuenzae type D S. aureus S. aureus S. aureus Streptococcus Group A Pneumococcus Meningococcus Klebsiella Gram-positive diplococci
Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Operation Pericardiocentesis Pericardiocentesis Pericardiocentesis Pericardiocentesis Autopsy
+
Blood cultures
Other
+
+
-(CIE+ )
+ + +
Nasopharynx Nasopharynx
+
Knee + Submandibular abscess Scalp, abscesses
+
+ + +
+ +
+
+ +
Throat
+
+
CSF, left hip Sputum
+
+
+
Legend: ClE, Countercurrent immunoelectrophoresis; CSF, Cerebrospinal fluid.
Table III. Treatment Case No. I
2 3 4 5
6 7
8 9 10 II
12 13 14 15
Organism
Major antibiotic
H. influenzae type B H. influenzae type B H. infiuenzae type B H. influenzae type B H. infiuenzae type B H. infiuenzae type B H. influenzae type D S. aureus S. aureus S. aureus Streptococcus Group A
Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Cephalothin Nafc illin Nafcillin Penicillin G
Pneumococcus Meningococcus Klebsiella Gram-positive cocci
Penicillin G Penicillin G Cephalothin, gentamicin, PON" Ampicillin
Duration of antibiotics (wk)
Initial pericardial drainage
No. of pericardiocenteses
PC PC PC PC P PC PC PC PC OP P
2
4 5
3 5
3 4
3 3 4
6 2 4 3
2 Until death
PC P P None
I I 4
2 I I I I 0 3 I I I
0
Operation
Results
AlP AlP AlP AIP TP AlP Tube
Good Good Good Good Good Good Good Good Good Good Needed reexploration Good Good Good Died
AlP Tube AlP
Legend: P, Needle pericardiocenteses. PC, Pericardiocentesiscatheter drainage. OP, Immediate operation. AlP, Anterior interphrenic pericardiectomy. TP, Total
pericardiectomy. Tube, Subxiphoid tube pericardiectomy.
pericardial window for adequate drainage. Anterior interphrenic pericardiectomies were performed in seven patients and a total pericardiectomy in one. A median sternotomy was used in five patients who had anterior interphrenic pericardiectomies and in the patient who had a total pericardiectomy. A left anterior thoracotomy was used in two of the patients who had anterior interphrenic pericardiectomies. No wound complications were noted with either incision. All of these patients recovered uneventfully with no instance of recurrent pericardial sepsis or tamponade and with no
significant complications. The length of hospitalization for these children was determined by the length of intravenous antibiotic therapy elected postoperatively. The 14 survivors have been followed for from 4 months to 13 years. None has had recurrent purulent pericarditis. All are in New York Heart Association Class I, and none is receiving cardiac medication. Discussion
This series demonstrates that purulent pericarditis, once a fatal disease, can now be treated successfully if
The Journal of
530 Morgan et al.
an appropriate management plan is followed. All of the patients in whom the diagnosis was made premortem survived with no complications on short- or long-term follow-up. General agreement exists that the treatment of purulent pericarditis requires both pericardial drainage and appropriate antibiotic therapy. The indications for operation and the preferable form of pericardial drainage have not been defined. The mortality for untreated cases approaches 100%.1, 2, 4, 5 The fact that antibiotic therapy alone is not sufficient is demonstrated by the death of the one patient in our series, who did not have pericardial drainage, and by the 82% mortality reported for antibiotic therapy alone in a previous report. 3 Pericardiocentesis can provide adequate drainage if the infected pericardial fluid is thin enough to flow through a needle or through a percutaneously placed drainage catheter. This was successful in four of the 12 cases in this series in which it was attempted. Patients who had recurrent pericardial sepsis or tamponade were not helped by repeated pericardiocenteses. Benzig and Kaplan" confirmed this finding. They reported that only one of six patients treated with multiple pericardiocenteses recovered, and the other five required operations. The reason that pericardiocentesis fails is probably that the pericardial pus is either loculated or too thick to flow through a needle. H. irfiuenzae usually produces such pus. All seven of the patients in our series with H. infiuenzae required operative intervention, as did all five patients reported by Cosgrove, Echeverria, and Sade" and all nine of the patients reported by Cheatham and associates. 7 Pericardiostomy can provide successful drainage and is sometimes recommended as the treatment of choice.?"!" However, pericardiostomy often provides inadequate drainage, as it did in one of our two patients in whom it was attempted. This is similar to the findings of Carneron.t" who reported that two of 10 patients with Staphylococcus aureus pericarditis treated with antibiotics and tube drainage died and three required at least one reexploration. Cameron believed that pericardiectomy was contraindicated because it was a "potential cause of bacteremia. " This complication was not seen in our patients who had pericardiectomy or in other series. 11 - 13 All of our pericardiectomy patients recovered without complications and none had subsequent pericardial sepsis or tamponade. A theoretical advantage of pericardiectomy over pericardial drainage is the prevention of late constrictive pericarditis. The incidence of this complication is not clear, but at least 20 cases have been reported. 14, 15
Thoracic and Cardiovascular Surgery
Ten were caused by Staphylococcus aureus, five by H. irfluenzae, three by meningococcus, and two by Pastuerella tularensis. The constriction typically occurs within 8 weeks of the acute illness and progresses rapidly. Constriction has occurred after treatment with antibiotics alone.'" and also after apparently adequate treatment with antibiotics and pericardiocentesis'" or pericardiostomy.l" None of our patients thus far has evidence of constriction. We conclude from the present series and from a literature review that immediate diagnostic and therapeutic pericardiocentesis should be performed for any child suspected of having purulent pericarditis. Early pericardiectomy should be performed if the causative organism is H. infiuenzae . In other patients, pericardiectomy should be performed immediately if tamponade occurs after initial pericardiectomy or if fever persists despite appropriate antibiotic therapy. We do not recommend multiple pericardiocenteses or tube drainage. REFERENCES
2 3
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5 6
7
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9 10 II
12 13
Okoroma EO, Perry LW, Scott LP III: Acute bacterial pericarditis in children. Report of 25 cases. Am Heart 1 90:709-713, 1975 Benzig G III, Kaplan S: Purulent pericarditis. Am 1 Dis Child 106:289-294, 1963 Feldman W: Bacterial etiology and mortality of purulent pericarditis in pediatric patients. Am 1 Dis Child 133: 641-644, 1979 Keith 1D, Rowe RD, Vlad P: Heart Disease in Infancy and Childhood, ed 3, New York, 1978, Macmillan Publishing Co., Inc. pp 250-251 Kauffman CA, Watanakunakom S, Phair 1P: Purulent pneumococcal pericarditis. Am 1 Med 54:743-749,1973 Cosgrove DM, Echeverria P, Sade RM: The management of Hemophilus irfiuenzae, Type B, pericarditis. Ann Thorac Surg 21:281-283, 1976 Cheatham JE 1r, Grantham RN, Peyton MD, Thompson WM, Luckstead EF, Razook 1D, Elkins RC: Hemophilus irfluenzae purulent pericarditis in children. 1 THORAC CARDIOVASC SURG 79:933-936, 1980 Wyler F, Knusli D, Rutishauser M, Stocker F, Weber 1, Real F: Pericarditis purulenta in children. Helv Paediatr Acta 32:135-140, 1977 Nghiem DD, Pate 1W: Purulent pericarditis in South Vietnam. South Med 1 67:1306-1307, 1974 Cameron EW1: Surgical management of staphylococcal pericarditis. Thorax 30:678-681, 1975 Echeverria P, Smith EWP, Ingram D, Sade RM, Gardner P: Hemophilus irfiuenzae b pericarditis in children. Pediatrics 56:808-818, 1975 Das PB, Ray D: Surgical management of pyogenic pericarditis. Int Surg 61:483-485, 1976 Sinclair MC: Acute pyogenic pericarditis. The role of pericardiectomy. E Afr Med 1 55: 136-142, 1978
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14 Strauss AW, Santa-Maria M, Goldring D: Constrictive pericarditis in children. Am J Dis Child 129:822-826. 1975 15 Weir EK, Joffe HS: Purulent pericarditis in children. An analysis of 28 cases. Thorax 32:438-443, 1977 16 Noonan JA. Walters LR, Bryant L. Toomey FS: Acute constrictive pericarditis following Hemophilus infiuenzae infection. Circulation 40:Suppl 3: 155. 1969 17 Caird R, Conway N. McMillan IKR: Purulent pericarditis followed by early constriction in young children. Br Heart J 35:201-203. 1973
Treatment of purulent pericarditis-a comment There are two considerations in treating patients with purulent pericarditis: (I) resolution of the acute infection and (2) prevention of constrictive pericarditis. Prompt and complete evacuation of the infected pericardial space and use of antibiotics are necessary to eliminate the acute infectious process. Morgan and his colleagues demonstrate quite nicely that needle or small-bore catheter pericardiocentesis and drainage are inadequate to evacuate the pericardial space effectively in the majority of patients with purulent pericarditis. However, the safest and most effective method of surgical drainage of the pericardial space remains to be defined. While the authors suggest that pericardiectomy should be performed in all cases of H. injluen::.ae pericarditis, it is possible that subxiphoid surgical drainage with a large-bore pericardiostomy tube would have been as effective as pericardiectomy if done shortly after diagnosis. The authors recommend pericardiectomy for patients with purulent pericarditis caused by an organism other than H. infiuenzae only if cardiac tamponade occurs or if fever persists despite appropriate antibiotic therapy. Some investigators, however, recommend early surgical pericardial drainage in all cases of purulent pericarditis regardless of the causative organism. It is vital that appropriate antibiotic therapy be utilized. Appropriate antibiotic therapy includes the correct antibiotic (confirmed by in vitro sensitivity testing), the correct dose (confirmed by serum antibiotic assay), the correct route of administration (intravenous), and the correct time (begun immediately upon diagnosis). The relationship between the technique of pericardial
Purulent pericarditis in children
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drainage and subsequent development of constrictive pericarditis is unknown. It is estimated that constrictive pericarditis will develop in 4% to 16% of patients who have had purulent pericarditis. I. 2 As Morgan and associates indicate, the occurrence of constrictive pericarditis will be rare following total pericardiectomy. However, if early subxiphoid surgical drainage of the pericardium with a large-bore pericardiostomy tube is as effective as pericardiectomy in preventing constrictive pericarditis, many patients could be spared the more substantial operative procedure of total pericardiectomy. David J. Driscoll, M.D. K. Hable Rhodes, M.D. Rochester, Minn. REFERENCES Boyle J, Pearce M, Guze L: Purulent pericarditis. Review of the literature and report of II cases. Medicine 41: 119144, 1961 2 Van Reken D, Strauss A, Hernandez A, Feigin R: Infectious pericarditis in children. J Pediatr 85: 165-169, 1974
Authors' response We certainly agree with most of the points made by Drs. Driscoll and Hable Rhodes in regard to our paper on purulent pericarditis. They raise the question as to whether subxiphoid surgical drainage with a large-bore tube placed 'in the pericardium might not be preferable to pericardiectomy. We believe that more data (a larger number of patients) are needed to settle this issue. In our experience the consistency of the purulent material in those patients with H. influenzae has been similar to that of scrambled eggs. The purulent material is not drained from the pericardium but actually scooped out at operation. Sometimes, friable lumps of the material have to be dissected off the heart and from around the great vessels. It seems unlikely that tube drainage would be successful in these cases. Richard J. Morgan, M.D. Larry W. Stephenson, M.D. Paul K. Woo({, M.D. Richard N. Edie, M.D. L. Henry Edmunds, Jr., M.D. Philadelphia, Pa.