Pericardiocentesis draining 690cc of purulent fluid in a patient with MSSA purulent pericarditis improved right atrial pressures from 18 to 8 mmHg and cardiac index from 1.8 to 2.3 L/min/m2.
Case Report (n=1)
Purulent pericarditis is a rare but life-threatening condition that can cause mixed obstructive and distributive shock, where early diagnosis with POCUS and prompt pericardiocentesis are critical for hemodynamic stabilization.
Abstract Introduction Purulent pericarditis resulting in obstructive shock (cardiac tamponade) and distributive shock is a rare, life-threatening condition. This case highlights a patient who developed obstructive shock and myocardial abscess in the setting of methicillin sensitive Staphylococcus aureus (MSSA) purulent pericarditis. Case Presentation A 73-year-old male with no prior medical history and limited interaction with the healthcare system presented to the emergency department with constipation, weakness, and fatigue. He was found to have new onset atrial fibrillation with RVR, evidence of prior anterior STEMI on EKG, and acute kidney injury (AKI). Initial TTE showed reduced ejection fraction of 29%, an LV apical aneurysm with thrombus, and a moderate pericardial effusion. He was started on a heparin drip. During hospitalization, he developed signs of shock with hypotension requiring levophed, elevated lactate, transaminitis, and anuria. He was transferred to the ICU where POCUS showed signs of cardiac tamponade including worsening effusion, dilated IVC and RV diastolic collapse. This was confirmed by repeat TTE showing increased respiratory variation in transmitral and transtricuspid flow velocities confirming tamponade. The patient underwent right heart cath showing elevated RA pressures of 18 mmHg and CI 1.8 L/min/m2. Interventional cardiology performed a pericardiocentesis and drained 690cc of purulent pericardial fluid. After drainage, RA pressures improved to 8 mmHg and CI to 2.3 L/min/m2. Blood and pericardial fluid cultures returned positive for MSSA. A contrasted CT scan of the chest showed the pericardial effusion with loculations and a collection at LV apex consistent with myocardial abscess. Patient was transferred to a quaternary hospital with cardiothoracic surgery for definitive surgical management. Discussion Purulent pericarditis constitutes less than 1% of all pericarditis cases. Such patients can develop both obstructive shock due to cardiac tamponade and distributive (septic) shock from bacteremia, purulent myocardial abscesses and infected cardiac thrombi. POCUS is an essential tool to help make early diagnosis. This abstract is funded by: None
Carlson et al. (Fri,) conducted a case report in Purulent pericarditis with mixed obstructive and distributive shock (n=1). Pericardiocentesis was evaluated on Hemodynamic improvement (Right atrial pressure and cardiac index). Pericardiocentesis draining 690cc of purulent fluid in a patient with MSSA purulent pericarditis improved right atrial pressures from 18 to 8 mmHg and cardiac index from 1.8 to 2.3 L/min/m2.