- Massimo Imazio, MD, FESC
Massimo Imazio, MD, FESC
- Contract Professor of Physiology
- University Cardiology, AOU Città della Salute e della Scienza di Torino and Department of Public Health and Pediatrics, University of Torino, Torino, Italy
- Section Editors
- Stephen B Calderwood, MD
Stephen B Calderwood, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine (Microbiology and Immunobiology)
- Harvard Medical School
- Martin M LeWinter, MD
Martin M LeWinter, MD
- Section Editor — Myopericardial Disease
- Professor of Medicine and Molecular Physiology and Biophysics
- University of Vermont
- Deputy Editors
- Brian C Downey, MD, FACC
Brian C Downey, MD, FACC
- Deputy Editor — Cardiology
- Assistant Professor of Medicine
- Tufts University School of Medicine
- Elinor L Baron, MD, DTMH
Elinor L Baron, MD, DTMH
- Deputy Editor — Infectious Diseases
- Assistant Clinical Professor of Medicine
- Tufts University School of Medicine
Prior to the widespread use of antibiotics, purulent pericarditis was a frequent complication of pneumococcal pneumonia. In modern times, most cases of purulent pericarditis are associated with nosocomial bloodstream infections (such as in the setting of dialysis), thoracic surgery, or immunosuppression (eg, HIV, chemotherapy).
Galen (AD 129 – 217) was one of the first clinicians to recognize and attempt to treat purulent pericarditis. While removing the "putrefied" sternum of a patient with posttraumatic pericarditis, he directly observed "mortification of the pericardium" in a patient who survived .
By the beginning of the 19th century, clinicians were aware that purulent fluid collections in the pericardium could occur in patients with pneumonia and pleurisy, and were attempting treatment with percutaneous drainage and pericardiectomy .
Issues related to purulent pericarditis will be reviewed here. Other causes of pericarditis and the management of acute pericarditis are discussed separately. (See "Etiology of pericardial disease" and "Clinical presentation and diagnostic evaluation of acute pericarditis" and "Treatment of acute pericarditis".)
Purulent pericarditis is defined as a localized infection of the pericardial space characterized by gross pus in the pericardium or microscopic purulence (>20 leukocytes per oil immersion field). This distinction is important since purulent material in the pericardium is not synonymous with infectious pericarditis, and not all infections produce purulent effusions. As an example, pericarditis due to Mycoplasma hominis or viral infection is rarely macroscopically or microscopically purulent. By contrast, a variety of noninfectious conditions produce an inflammatory exudate that may contain >50,000 white cells/microL .
- Rubin RH, Moellering RC Jr. Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med 1975; 59:68.
- Boyle JO, Pearce ML, Guze LB. Purulent pericarditis. Review of the literature and report of eleven cases. Medicine (Baltimore) 1961; 40:119.
- Kenney RT, Li JS, Clyde WA Jr, et al. Mycoplasmal pericarditis: evidence of invasive disease. Clin Infect Dis 1993; 17 Suppl 1:S58.
- Sagristà-Sauleda J, Barrabés JA, Permanyer-Miralda G, Soler-Soler J. Purulent pericarditis: review of a 20-year experience in a general hospital. J Am Coll Cardiol 1993; 22:1661.
- Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis: an 86 year autopsy experience in 200 patients. Am J Med 1977; 63:666.
- Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
- Kauffman CA, Watanakunakorn C, Phair JP. Purulent pneumococcal pericarditis. A continuing problem in the antibiotic era. Am J Med 1973; 54:743.
- Miller WL, Osborn MJ, Sinak LJ, Westbrook BM. Pyopneumopericardium attributed to an esophagopericardial fistula: report of a survivor and review of the literature. Mayo Clin Proc 1991; 66:1041.
- KATZ A. ABSCESS OF THE MYOCARDIUM COMPLICATING INFARCTION: REPORT OF TWO CASES. Can Med Assoc J 1964; 91:1225.
- Schoenkerman AB, Lundstrom RJ. Coronary stent infections: a case series. Catheter Cardiovasc Interv 2009; 73:74.
- Ochsner A, DeBakey ME. Subphrenic abscess: Collective review and analysis of 3608 collected and personal cases. Int Abstr Surg 1938; 66:426.
- Ochsner A, DeBakey ME. Amebic hepatitis and hepatic abscess: analysis of 181 cases with review of the literature. Surgery 1943; 13:460.
- Myer HW. Pneumopyopericardium. J Thorac Cardiovasc Surg 1948; 17:62.
- Parikh SV, Memon N, Echols M, et al. Purulent pericarditis: report of 2 cases and review of the literature. Medicine (Baltimore) 2009; 88:52.
- Brook I. Pericarditis caused by anaerobic bacteria. Int J Antimicrob Agents 2009; 33:297.
- Schrank JH Jr, Dooley DP. Purulent pericarditis caused by Candida species: case report and review. Clin Infect Dis 1995; 21:182.
- Kraus WE, Valenstein PN, Corey GR. Purulent pericarditis caused by Candida: report of three cases and identification of high-risk populations as an aid to early diagnosis. Rev Infect Dis 1988; 10:34.
- Cegielski P, Dukes CS. Pericardial effusion in AIDS. Circulation 1997; 96.
- Imazio M, Cecchi E, Demichelis B, et al. Myopericarditis versus viral or idiopathic acute pericarditis. Heart 2008; 94:498.
- Nwiloh JO, Egbe PA, Tagoe AT, Weaver LW. Staphylococcus aureus pericarditis masquerading as anterior mediastinal mass: mediastinal mass from pericarditis. Chest 2000; 118:1832.
- Pierce HI, Cooper EB. Meningococcal pericarditis. Clinical features andd therapy in five patients. Arch Intern Med 1972; 129:918.
- Morse JR, Oretsky MI, Hudson JA. Pericarditis as a complication of meningococcal meningitis. Ann Intern Med 1971; 74:212.
- Salem K, Mulji A, Lonn E. Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardiol 1999; 15:1251.
- Nakagawa C, Kasahara K, Yonekawa S, et al. Purulent pericarditis due to Streptococcus pneumoniae diagnosed by pneumococcal urinary antigen assay and 16S rDNA sequence of the pericardial fluid. Intern Med 2010; 49:1653.
- Augustin P, Desmard M, Mordant P, et al. Clinical review: intrapericardial fibrinolysis in management of purulent pericarditis. Crit Care 2011; 15:220.
- Imazio M, Brucato A, Mayosi BM, et al. Medical therapy of pericardial diseases: part I: idiopathic and infectious pericarditis. J Cardiovasc Med (Hagerstown) 2010; 11:712.
- Van Trigt P, Douglas J, Smith PK, et al. A prospective trial of subxiphoid pericardiotomy in the diagnosis and treatment of large pericardial effusion. A follow-up report. Ann Surg 1993; 218:777.
- Predisposing factors
- Direct spread of infection from an intrathoracic focus
- Hematogenous spread
- Extension from a myocardial focus
- Perforating injury or surgery
- Extension of infection from a subdiaphragmatic suppurative focus
- CLINICAL MANIFESTATIONS
- Laboratory findings
- Additional investigations
- Pericardial drainage
- Antimicrobial therapy
- - Empiric regimen
- - Pathogen-directed therapy
- - Duration of therapy