Purulent pericarditis

Author Ольга Кияница

2019-03-03

Different forms of pericarditis can develop in different ways, but purulent pericarditis is noted the most unfavorable course. When it is high risk of mortality, especially in the absence of timely treatment. Therefore, operative diagnosis with subsequent thorough therapy is extremely important.

Pericarditis is an inflammation of the pericardium, or the so-called pericardial bag. The main function of the pericardium is to protect the heart from mechanical injuries, as well as to reduce the friction force that occurs during heart contractions. There are various forms of pericarditis, but the most unfavorable prognosis is observed with purulent formation.

The development of purulent pericarditis in most cases is based on the reason such as the infectious flora.

Timely diagnosis is of great importance, for which it is primarily used echocardiography, and, if necessary, ECG and CT.Treatment depends on the underlying cause and the clinical severity of the disease, but in any case, the doctor’s instructions must be followed, which reduces the risk of death.

Video: Pericarditis and pericardial effusions causes, symptoms, diagnosis, treatment, pathology

Description of purulent pericarditis

Purulent pericarditis (HF) develops due to an infection that has entered the pericardial space, which contributes to the production of a purulent fluid at a macroscopic or microscopic level. The disease can develop primarily (which is extremely rare) or secondarily with respect to another infectious process.

There are five pathogenic mechanisms that can lead to invasion of the pericardial space, causing secondary purulent pericarditis:

  • The spread of infection from adjacent areas , most often located inside the chest.
  • Hematogenous spread - the infection enters the pericardium through the blood vessels.
  • Myocardial infection - for various diseases, mainly myocarditis, infection occurs in the adjacent pericardium.
  • Penetrating trauma or surgery - in case of injury and surgery, the pathogen can be introduced into the pericardium or surrounding tissues.
  • Distribution from the subdiaphragmatic area - meaning that when the diaphragm is infected, the pathogen can enter the adjacent pericardium.

It should be noted that pneumococcus most often has a direct connection with the continuous spread from the organs of the thoracic cavity, whereas Staphylococcus aureus often infects the pericardium through the hematogenous route of transmission.

Purulent pericarditis is now very rare. Most often it is determined in people with previous pericardial diseases or who have undergone chemotherapy.

Additionally, the following risk factors for purulent pericarditis:

  • The transfer of heart surgery.
  • The passage of dialysis.
  • Immunosuppression.
  • Alcoholism.
  • Chest injury.

Before the advent of antibiotic therapy, GP was a common complication of pneumonia, endocarditis, meningitis, and other infections of varying severity, including infectious lesions of the bone, skin, and ear.

A retrospective analysis conducted in a Spanish hospital involving 593,601 patients from 1972 to 1991, revealed 33 cases of purulent pericarditis, of which only 19 (57%) were diagnosed during life, mainly because such a diagnosis was considered.

Causes of purulent pericarditis

In a study conducted in the United States, it was determined that purulent pericarditis occurred most often in children and after 50 years, and much less frequently in other age groups. In developing countries, HF is a common complication of severe infection (especially due to Staphylococcus aureus or Streptococcus) in children.

Until 1940, the ratio of men and women with GP was 4: 1, but later the incidence of the disease between the sexes became the same.

Organisms that cause purulent pericarditis:

  • Most often, purulent pericarditis causes staphylococci, streptococci, and gram-negative organisms, such as proteus, Escherichia if, pseudomonads and Klebsiella.
  • Neisseria meningitidis, which accounts for about 3% of all cases of purulent pericarditis, usually causes pericarditis after meningococcemia in patients with meningitis.
  • Fungi and protozoa are rarely determined, but it is increasingly clear that the main cause of purulent pericarditis is weakened immunity, and myocardial damage by fungus usually precedes the development of pericarditis.

Rare causes of purulent pericarditis

Bacterial Non-bacterial
Actinobacillus (Actinobacillus)
Legionella
Hemophilic infection (Haemophilus influenzae)
Bacterium group HACEK (Eikenellal corrodens)
The causative agent of tularemia (Francisella tularensis) The causative agent of histoplasmosis (Histoplasma)
Causative agent of blastomycosis (Blastomyces)
Causative agent of coccidiosis (Coccidioides)
Causative agent of aspergillosis (Aspergillus)
Causative agent of candidiasis (Candida)
Causative agent of toxoplasmosis (Toxoplasma)
Causative agent of nocardiosis (Nocardia)
Causative agent of amebiasis (Entamoeba)

Acute Purulent Pericarditis

With the development of the acute form of the disease, symptoms and signs most characteristic of purulent pericarditis attract attention first of all. Most often it takes place as an acute febrile process. In this case, the presence of a co-infection, which is usually the cause of the disease, may mask the main symptoms and signs of purulent pericarditis.

The following main clinical features of the disease are distinguished:

  • Fever
  • Dyspnea
  • Chest pain
  • Paradoxical pulse (Pulsus paradoxus)
  • Hepatomegaly
  • Increased central venous pressure
  • Pericardial friction noise
  • Ascites

Most patients complain of fever and quite a lot of shortness of breath, but only half have chest pain during a physical examination. Also, there are often no “classic” signs, such as an increase in central venous pressure or the definition of a paradoxical pulse.

The most common associated infectious diseases in patients with purulent pericarditis (based on research) are as follows:

  • Pneumonia (especially pneumococcal).
  • Otitis media
  • Meningitis (especially meningococcal).
  • Skin infectious diseases.
  • Staphylococcal osteomyelitis.
  • Subdiaphragmatic abscesses.

Additionally, it is important to point out that in patients with suspected acute purulent pericarditis, noncardiac infectious diseases can actually be determined, such as systemic fulminant lupus erythematosus, erythematosis, empyema, acute myocardial infarction and malignant neoplasm.

Diagnosis of purulent pericarditis

The appearance of echocardiography has significantly improved the quality of diagnosis of pericardial diseases.

Additionally can be used:

  • Computed tomography , which provides adequate visualization.
  • Electrocardiography in 12 standard leads, which allows to determine tachycardia.
  • Radiography of the chest, often indicating an enlarged heart diameter.
  • Complete blood count , which makes it possible to identify leukocytosis and other pathological changes in the blood.

Depending on the type of concomitant disease, bacteriological blood cultures can be prescribed and the erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase levels, serum titers, etc. can be determined.

Purulent pericarditis: treatment

There are general principles of treatment of purulent pericarditis, which apply to the majority of patients with this disease.

  • Treatment includes drainage of the pericardial space.
  • Systemic antibiotic therapy is used, and vancomycin and ceftriaxone or imipenem, meropenem, or piperacillin-tazobactam can be used initially, along with fluconazole, especially in immunocompromised patients, and then corrected according to the results of microbiological research.

It is worth noting that local antibacterial therapy is not beneficial. Antibiotic treatment should continue for at least 28 days or until the temperature subsides and there are no laboratory signs of infection.

First aid for purulent pericarditis and various complications

Emergency care for patients with HP is aimed at prompt diagnosis and treatment of patients in a potentially life-threatening condition. Thoracotomy and pericardiotomy may be necessary if the patient has a rapid deterioration or cardiac arrest. Together with GP, effusion or cardiac tamponade can be determined.

Vypotnoy GP

Ideally, echocardiography can determine the presence or absence of effusion in the pericardium. If there is no pericardial effusion, the patient is in a stable condition and the suspected cause of the disease are viruses, then the patient can be discharged with appropriate instructions and follow-up. If there is a large effusion, a pericardiocentesis or a pericardial window can be recommended for a stable patient.

Heart tamponade

Treatment of this condition depends on the stability of the patient. If you are unstable, you may need immediate treatment for increasing pericardial pressure with pericardiocentesis. Sometimes removal of only 30-50 ml can lead to a significant improvement in hemodynamics. A subacute tamponade can also be noted (periodically with decompression) and then the cardiothoracic effect used to treat heart injuries is helpful.

Video: Causes of pericarditis | Circulatory System and Disease | NCLEX-RN | Khan Academy

Surgical treatment of purulent pericarditis

The strategy adopted to achieve full drainage of the pericardial space will depend on the human and technical resources of the institution that treats the patient. Depending on the situation and indications, pericardiocentesis, pericardiotomy, pericardectomy can be performed.

Pericardiocentesis . This is the easiest and fastest method, but often it is ineffective when draining thick purulent fluid.This method of exposure can also lead to the development of constrictive pericarditis. Intrapericardial infusion of fibrinolytics or antibiotics can increase the therapeutic efficacy of pericardiocentesis. In determining the connection with complications, this method of therapy is usually not recommended.

Pericardiotomy (creation of a pericardial window). This is the method mentioned in the recommendations of the European Society of Cardiology, since it is associated with a higher success rate and a lower incidence of constrictive pericarditis.

Pericardiectomy . When used, the risk of death increases to 8%, but it is this approach that allows you to resolve all situations, even the most complex ones associated with spikes, localized effusions or permanent infection.

Without drainage of the pericardial space, purulent pericarditis inevitably leads to death. Mortality in patients who were quickly diagnosed and properly cured is 40%, usually due to cardiac tamponade, septic shock, or narrowing of the pericardial space. Mortality increases, the longer the disease is diagnosed, as well as with delayed appropriate treatment. The risk of death is particularly high in patients with S. aureus infection and with a severe depletion of the body.

Purulent pericarditis: photo

Thoracoabdominal computed tomography. Frame 1: liver abscess image (arrow B) extending towards the extrathoracic region along the subcutaneous plane (arrow A). Frame 2: Image of a severe pericardial effusion.

An echocardiogram (subsyphoid view) shows a peripheral pericardial effusion (marked with *).

(A) Transthoracic echocardiogram showing an expanded inferior vena cava (IVC), which is often observed with cardiac tamponade. (B) Green pericardial fluid obtained after emergency pericardiocentesis, in which the bacterial flora multiplied.

Conclusion

Purulent pericarditis is a rare disease, but is considered one of the complications of pneumonia and other infectious pathologies that can increase in their frequency, especially in the group of patients with weakened immune systems.“Classical” symptoms and signs are often absent (especially with a disorder of the immune system).

Echocardiography followed by pericardiocentesis are commonly used studies. If the diagnosis is established early, then after an appropriate treatment an excellent prognosis is given. GP therapy mainly consists of antibiotics and surgery, which is selected based on individual indications.

Video: Pericarditis


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