Introduction
Purulent pericarditis is a rare but serious condition involving inflammation of the pericardium, the sac-like membrane surrounding the heart. It is caused by a bacterial infection that leads to the accumulation of pus in the pericardial space. In the largest recent single series of patients from the USA (United States of America), purulent pericarditis occurred most frequently in children and the fifth decade, although cases occurred in all age groups. It is a not infrequent sequela of severe infection in the developing world. A high level of awareness is required because 'classical' symptoms and signs are frequently absent (especially in the immunocompromised). The preferred investigations are echocardiography followed by computed tomography. If the diagnosis is made early, the prognosis is excellent after appropriate treatment, including antibiotics and surgical intervention if necessary.
What Is Purulent Pericarditis?
Pericarditis refers to inflammation of the pericardium. Pericardium refers to the layers of the heart that protect the heart. Purulent pericarditis is a rare but serious bacterial infection that affects the heart's inner lining, including the heart valves. This condition is caused by bacteria entering the bloodstream and attaching to damaged heart valves or other areas of the heart. Purulent pericarditis can be life-threatening if not promptly diagnosed and treated.
What Causes Purulent Pericarditis?
Pericarditis can be caused by a variety of infectious and noninfectious processes. The majority of cases of acute community-onset pericarditis in the United States are idiopathic (unknown cause) and are caused due to viruses. Mostly these are self-limited.
The following are the causes of the purulent pericarditis:
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Virus: Viral agents that cause acute pericarditis include enteroviruses (coxsackievirus A and B, echovirus), mumps, influenza, Epstein-Barr virus, varicella-zoster virus, herpes simplex virus, and hepatitis B virus.
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Noninfectious Causes: Noninfectious causes of pericardial effusion include malignancy either due to direct involvement of the pericardium (layers of the heart) with cancer or obstruction of the lymphatic drainage of the pericardium.
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Inflammation: Purulent pericarditis is also caused due pericardial inflammatory disease and is characterized by gross pus (infectious collection of the fluid in the pericardium) in the pericardial sac. It is usually due to direct infection of the pericardial space with a bacterial infection, but occasionally other infectious and noninfectious agents and processes can produce this syndrome.
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Other Pathogen: Staphylococcus aureus and Enterococcus is the most common pathogen seen to cause purulent pericarditis. Staphylococcus aureus and Streptococcus pneumoniae cause purulent pericarditis in association with lung infection.
What Are the Risk Factors for Purulent Pericarditis?
Purulent pericarditis is caused by a bacterial infection that enters the bloodstream and attaches to damaged areas of the heart, particularly the heart valves. The most common bacteria that cause purulent pericarditis include Staphylococcus aureus and Streptococcus viridans, but other bacteria can also be responsible.
The following are the risk factors for purulent pericarditis:
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The bacteria that cause purulent pericarditis can enter the bloodstream through various means, such as dental procedures, surgical procedures, intravenous drug use, and other infections throughout the body.
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The bacteria can then attach to damaged heart valves or other areas of the heart, leading to the formation of bacterial colonies or "vegetations" on the affected areas.
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Individuals with certain risk factors are more susceptible to developing purulent pericarditis.
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These risk factors include having a pre-existing heart condition, such as congenital heart disease or heart valve abnormalities, having undergone previous heart surgery or dental procedures, and intravenous drug use.
What Are the Symptoms of Purulent Pericarditis?
Purulent pericarditis presents as an acute fever-type illness. The low diagnosis rate is evidence of the lack of definitive localizing symptoms and signs in the disease. The presence of the co-existence of other diseases, such as pneumonia, can mask underlying signs and symptoms of purulent pericarditis. The commonest co-existent infections in purulent pericarditis are pneumonia (particularly pneumococcal), otitis media, meningitis (particularly meningococcal), skin infection, staphylococcal osteomyelitis, and subdiaphragmatic abscesses.
The following are the symptoms of purulent pericarditis:
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Difficulty in breathing.
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Chest pain.
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High fever and chills.
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Liver enlargement (hepatomegaly).
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Rapid heartbeat.
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Fatigue.
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Persistent cough.
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Shortness of breath.
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Nausea and vomiting.
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Weight loss.
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Blood in the urine.
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Joint pain.
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Headaches.
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Low blood pressure (hypotension).
How Is Purulent Pericarditis Diagnosed?
The initial evaluation of patients with pericarditis may be done on an outpatient basis or in the emergency department. Diagnostic studies, including chest radiography, electrocardiography, and echocardiography, are usually confirmatory.
The following are the ways to diagnose purulent pericarditis:
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Blood Tests: The routine blood test can detect the presence of the infection. Leucocytosis (increased number of white blood cells) can indicate the presence of inflammation.
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Echocardiography: The advent of echocardiography has greatly improved the ability to diagnose pericardial collections accurately.
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Computerized Tomography: Computerized tomography (CT) scan provides adequate heart imaging and helps in proper diagnosis.
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Chest X-ray: In 73 percent of the cases, a plain chest X-ray shows the changes in the pericardium.
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Cytology: Cytology should also be performed on the pericardial fluid to exclude an underlying malignancy (cancer) involving the pericardium with infection of an associated effusion.
How Is Purulent Pericarditis Treated?
Treatment of purulent pericarditis typically involves hospitalization and the administration of antibiotics to eliminate the bacterial infection. In some cases, drainage of the pus may also be necessary to relieve pressure on the heart and prevent further complications. Surgery may also be required in severe cases.
The treatment of the purulent pericarditis requires four steps:
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Medication: The first step is to diagnose the disease's bacterial or pathogenic cause. After that, empiric antibiotic treatment depends on the presence of any significant underlying illnesses in the patient. Medication includes a third-generation Cephalosporin (Ceftriaxone or Cefotaxime) is recommended owing to the increased isolation of penicillin-resistant Streptococcus pneumoniae in many treatment settings. When a life-threatening infection exists, as with purulent pericarditis, the addition of Vancomycin is appropriate. Levofloxacin or Ciprofloxacin is suggested in case of causative agents of Legionella and Mycoplasma species.
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Drainage: Secondly, drainage should be performed as soon as the diagnosis is confirmed.
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Surgery: Third, a subset of patients will require removal of the pericardium to treat disease or to prevent later complications.
Conclusion
Purulent pericarditis is a rare but serious complication of pneumonia and other infectious diseases that may be on the rise, particularly among immunocompromised patients. It is important to seek medical attention promptly if someone experiences any symptoms associated with purulent pericarditis, as delayed or inadequate treatment can lead to severe complications, including heart failure and stroke. It is important to practice good hygiene, maintain regular dental care, and promptly seek medical attention for any infections to reduce the risk of developing purulent pericarditis. People with known heart conditions or other risk factors may require prophylactic antibiotics before certain medical procedures to reduce the risk of developing this serious condition. Early diagnosis and appropriate management can result in an excellent prognosis.
