Purulent pericarditis caused by a bad tooth

A 14-year-old male was admitted for chest distress. Eight days ago, he picked his decayed tooth and experienced bleeding (Panel A, the arrow points to the bad tooth). An expansile submaxillary mass, diagnosed as cellulitis, appeared in 2 days (Panel B, CT showing the mass). Antibiotics were started and operative drainage was adopted (Panel C). But there was little improvement in the patient's condition and he began feeling chest distress. An echocardiogram showed much fluid in the pericardial cavity (Panel D). Ultrasound-guided percutaneous centesis was performed, and 1000 mL of pericardial pus was drained. The pus was sent for testing. Streptococcus anginosus was cultured, which was sensitive to vancomycin. Three days after vancomycin treatment, the amount of drained liquid decreased significantly. But another echocardiogram showed that there was still much pericardial pus. Another centesis was done, but unfortunately, the drainage tube lacerated the heart (Panel E, the right and left arrow points to the first and second drainage tube, respectively; Panel F, CT showing the thickened pericardium and drainage tubes).