Purulent Streptococcus pneumoniae pericarditis presenting as cardiac tamponade in an immunocompromised patient: case report

Background: Purulent bacterial pericarditis is an exceptionally rare but rapidly progressive cause of acute pericarditis in the modern antibiotic and pneumococcal vaccination era. Despite its low incidence, delayed recognition carries a high risk of cardiac tamponade, septic shock, constrictive pericarditis, and death. Case Presentation: We report the case of a 64-year-old man with pulmonary and hepatic sarcoidosis and well-controlled human immunodeficiency virus (HIV) infection receiving highly active antiretroviral therapy with an undetectable viral load, who presented with pleuritic chest pain and progressive dyspnea. Initial evaluation demonstrated diffuse ST-segment elevations on electrocardiogram and a moderate pericardial effusion without tamponade physiology on transthoracic echocardiography. Computed tomography revealed multifocal pneumonia, prompting empiric antimicrobial therapy. Despite initial management, the patient rapidly deteriorated with hypotension and acute hypoxic respiratory failure. Repeat echocardiography demonstrated evolving cardiac tamponade, necessitating emergent pericardiocentesis. Blood cultures and pericardial fluid cultures both yielded Streptococcus pneumoniae, confirming purulent pneumococcal pericarditis and allowing targeted antimicrobial therapy. The patient subsequently developed recurrent pericardial effusion following drain removal, and he recovered with continued medical management without requiring repeat intervention. Conclusion: This case highlights the diagnostic challenge of purulent pneumococcal pericarditis in immunocompromised patients, particularly when presenting with concurrent pneumonia and initially absent tamponade physiology. Early echocardiographic recognition, prompt source control with pericardial drainage, microbiologic confirmation, and guided antimicrobial therapy remain essential to reducing the substantial morbidity and mortality associated with this uncommon but life-threatening condition.