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Polymicrobial bacterial pericarditis with mediastinitis after traumatic endotracheal intubation is an unusual condition. We report a 54-year-old man, a victim of nasopharyngeal carcinoma, who developed pericardial effusion with tamponade after traumatic endotracheal intubation. The diagnosis of polymicrobial bacterial pericarditis was made when pericardiocentesis revealed purulent fluid that grew a mixed culture of anaerobic and aerobic bacteria, reflecting the normal upper airway flora. By bronchoscopic study, a laceration over the lower trachea was detected. The patient received prolonged aggressive antibiotic therapy and pericardial drainage. The infection improved, but the patient later died from another episode of nosocomial infection.

Vor 10 Monaten trat bei einer 63-jahrigen Patientin ein Vorderwandmyokardinfarkt (ST-Hebungsinfarkt) bei koronarer 1-Gefaserkrankung auf; es erfolgte eine Stent-Implantation des Ramus interventricularis anterior. Postinfarziell kam es zu einem Ventrikelseptumdefekt und Ventrikelaneurysma der Vorderwand, die operativ versorgt wurden. In der Folge traten wiederholt Harnwegsinfekte auf. Nun wird die Patientin mit Kollaps und beginnender Sepsis stationar aufgenommen. Im EKG zeigen sich bei einer Frequenz von 118 / min praterminale T-Negativierungen in Ableitung V3-V6. Die Rontgen- und CT-Aufnahmen des Thorax ergeben 3 pathologische Befunde (▸ Abb. 1 ).

Purulent bacterial pericarditis is an uncommon form of infectious pericarditis, occurring usually in immunocompromised patients. It may rarely present as a nodular or tumefactive lesion, and in such cases is liable to be confused with primary and metastatic tumors. We describe the imaging features and diagnostic contribution of CT and MRI in a 68-year-old woman with mass-like purulent pericarditis.

Two-dimensional echocardiography demonstrated a pseudoaneurysm of the lateral wall of the left ventricle in a 13-year-old girl with bacterial pericarditis. The echocardiographic findings included a 5-mm discontinuity in the lateral wall of the left ventricle, an associated anechoic collection (5.6 x 5.1 cm), and a narrow communication between the left ventricle and the anechoic collection. Color Doppler imaging demonstrated flow through the communication between the left ventricle and the aneurysmal cavity. The patient and her family refused surgery. A follow-up echocardiographic examination more than 6 years later demonstrated disappearance of the discontinuity of the left ventricular lateral wall, no flow between the left ventricle and the pseudoaneurysm, and thrombus formation within the pseudoaneurysm.

Purulent pericarditis is rarely the primary site of bacterial infection. It is usually a complication of an infection originating elsewhere in the body, arising by contiguous spread or haematogenous dissemination.This paper, however, describes a previously healthy young man, who developed a purulent streptococcal pericarditis with no localizable primary focus. Although many possibilities were investigated, the entry site of the pericarditis remains unknown. The incidence of purulent pericarditis has decreased considerably since the antibiotic era. It is typically an acute and potentially lethal disease, necessitating rapid diagnosis and adequate therapy to improve prognosis. Standard treatment combines appropriate antibiotic therapy with surgical drainage. However, the exact timing and type of surgery is still under discussion. Our patient was treated with antibiotics, subxiphoidal tube drainage of the pericardial fluid and intrapericardial thrombolysis. After three weeks, he developed tamponade, requiring partial pericardiectomy. He recovered completely and resumed his normal activities after a two-month hospitalisation.

A 19‐year‐old man was admitted with a history and examination findings of probable bacterial pericarditis. Blood cultures produced Neisseria meningitidis Group C, sensitive to penicillin. The patient was initially treated with intravenous benzylpenicillin. Echocardiogram demonstrated the development of a pericardial effusion which was tapped, and benzylpenicillin was instilled into the pericardial space. Because of failure of clinical resolution, cefotaxime was substituted forbenzyl penicillin. Rapid clinical improvement then ensued. Repeat echocardiogram showed evidence of neither reaccumulation nor constrictive pericarditis. Primary (isolated) meningococcal pericarditis is a recognized though rare manifestation of meningococcal disease. It is most common in young adults and is associated with a good prognosis.

9 Bacterial infection of the pericardium is uncomThe white cell count was normal: 9.4310 / l (normal, 9 mon. The advent of antibiotics and the decline of 4–11310 / l). Warfarin was reversed with 10 mg of tuberculosis has seen a decrease in the incidence of intravenous vitamin K prior to pericardiocentesis. A acute purulent pericarditis [1,2]. However, acute pericardial drain was left in situ draining a total of bacterial pericarditis remains a life-threatening con1.5 l of blood-stained fluid over 6 days. Intravenous dition with a mortality rate of 50% or more [3]. cefotaxime was commenced empirically and changed Diagnosis remains a significant challenge due to the to intravenous ciprofloxacin on identification of Salnon-specific presentations of pericardial disease. monella typhimurium from the pericardial aspirate. A 48-year-old travelling sales manager presented Blood and stool culture were negative. Repeat echto us with a 3-week history of flu-like symptoms, ocardiogram confirmed resolution of the effusion and anorexia, diarrhoea, and weight loss. He gave a 1the patient made a good clinical recovery. He was week history of chest pain, rapidly progressing discharged home on a 1-month course of ciprodyspnoea, palpitations, pyrexia, nausea, and vomitfloxacin. ing. The patient had been cardioverted from atrial Salmonellosis is a common health problem worldfibrillation to sinus rhythm 2 months previously. wide [1,3]. Extra-intestinal salmonella infections On examination he was tachycardic and tachymake up less than 30% of presentations [1]. Pericarpnoeic with a pyrexia of 38 8C. Heart sounds were dial salmonellosis is rare, accounting for less than 2% muffled. Jugular venous pressure was not raised and of extraintestinal presentations [3]. In a review of 232 there was no peripheral oedema, pericardial rub or cases of pericarditis, Preble identified only four cases added heart sounds. The electrocardiogram showed secondary to typhoid fever [4]. 2:1 atrial flutter. The cardiothoracic ratio was inCohen et al. described the first nontyphoidal salcreased on chest radiograph. Transthoracic echomonella (NTS) pericarditis in 1936 [5]. cardiography demonstrated a pericardial effusion A review of the published literature to date illus(Fig. 1). trates the non specific presentation of NTS pericarInflammatory markers were raised: C-reactive proditis (Table 1) [1,6]. Salmonella typhimurium is the tein 87 mg/ l (normal, 0–10 mg/ l) and erythrocyte commonest single organism implicated in NTS sedimentation rate 68 mm/h (normal, 1–10 mm/h). pericarditis, identified in a third of the reports. Silent gastroenteritis preceding the pericarditis is well rec*Corresponding author. Royal Brompton Hospital, Department of ognized [2,3]. Most reports emphasize the necessity Respiratory Medicine, Sydney Street, London SW3 6NP, UK. Tel.: of either pericardiocentesis or pericardiectomy in 144-20-7352-8121. E-mail address: rbadawi@msn.com (R. Badawi). conjunction with protracted antibiotic therapy for

Bacterial pericarditis has been recognized as a rare disease since the development of antibiotics. Usually, the disease is associated with underlying conditions or a seeding of infection elsewhere to the pericardium. Here we describe a case of group G streptococcal pericarditis as an initial presentation of colon cancer. A 52-yr-old man was admitted because of dyspnea. An electrocardiogram showed a diffuse ST-segment elevation and a two-dimensional echocardiogram showed a large amount of pericardial effusion. A pericardiocentesis was done and purulent fluid was drained. Group G streptococci was cultured in pericardial fluid. The patient was treated with antibiotics and pericardiostomy with saline irrigation. A colonoscopy revealed a small mass with moderately differentiated adenocarcinoma in rectosigmoid colon. He underwent a mucosectomy and was recovered without any complication.

A 57-year old woman was admitted to our hospital with massive pericardial fluid. Culture of the pericardial fluid was negative, however, Binax NOW® Streptococcus pneumoniae urinary antigen test was positive in pericardial fluid. 16S rDNA sequencing and PCR for lyt(A) gene of the pericardial fluid sample confirmed the microbiological diagnosis of S. pneumoniae. The patient was treated with surgical drainage and continuous intravenous infusion of penicillin G and its concentration in the serum and pericardial effusion was monitored. Incorporation of molecular methods such as antigen testing and nucleic acid sequencing would benefit the management of infectious diseases especially in culture negative cases.

This paper describes a case of a 44-year-old male patient previously healthy admitted with an unusual spontaneous acute bacterial pericarditis associated with coronary sinus mass. Two-dimensional echocardiography showed large loculated pericardial effusion with signs of diastolic restriction and an image suggesting vegetation in topography of the right atrium coronary sinus. Pericardial drainage, coronary sinus vegetation resection, and antibiotic therapy with Oxacillin were performed due to Oxacillin-susceptibleStaphylococcus aureusidentified on the pericardial effusion and blood culture. This is a rare condition and a unique combination of a spontaneous acute bacterial pericarditis with coronary sinus endocarditis without cardiac valve compromise.

A 58-year-old man was admitted for relapsing pericarditis. His past medical history included a transient ischemic attack when he was 47 years old, radical right nephrectomy for neoplasia 8 years earlier, and hypertension. One year earlier, a diagnosis of pleuropericarditis was made in another hospital. The patient was febrile and complained of chest pain; an echocardiogram showed thickening of parietal pericardium, hyperechoic matter on visceral pericardium, and the presence of pericardial and pleural effusion, without hemodynamic impairment. Concomitantly, the patient had a dental abscess; cultures from this abscess were negative during antibiotic therapy. He was treated empirically with piperacillin/tazobactam for 15 days and then with amoxicillin/clavulanate for ≈1 month and …

Twelve cases of purulent pericarditis seen over 6 years are described. Staphylococcus aureus was the most common causative organism (six patients), and a respiratory infection was the most common preceding illness. The chest radiograph and echocardiogram were useful pointers to the diagnosis, but the electrocardiogram was not reliable. Antibiotics, surgical drainage, and pericardiectomy were used in all 12 cases. There was one death (8.3%), which occurred in a patient who was seen late. A review of the literature dealing with the diagnosis and management of this condition is presented. The importance of early diagnosis before a significant degree of cardiac tamponade occurs is noted. Although there is general agreement that surgical drainage is mandatory, the approach, methods of drainage, and extent of pericardial resection have been the subject of some discussion, and at least seven techniques are available. We conclude that pericardiectomy has a definite place in the management of purulent pericarditis.

Pericarditis is one of the most frequent manifestations of systemic lupus erythematosus; however, purulent pericarditis and tamponade are rare. We describe a patient with systemic lupus erythematosus and culture-proven gonococcal arthritis who developed purulent pericarditis with intracellular gram-negative diplococci. Evidence of tamponade was seen on echocardiography. There has not been a reported case of Neisseria gonorrhoeae in pericardial fluid or tissue since the introduction of antibiotics.

Bacterial endocarditis is a complex disease that is associated with significant morbidity and mortality. Staphylococcus aureus is an organism commonly responsible for acute bacterial infective endocarditis. Patients many times develop an acute fulminant infection resulting in multiple complications, even in the face of adequate therapy. We report an unusual case of S aureus acute bacterial infective endocarditis in an immunocompromised patient resulting in multiple cardiac complications, including bacterial pericarditis with effusion, mycotic aneurysm of one of the coronary arteries, a valvular vegetation leading to an aneurysmal dilatation at the mitral-aortic junction (intervalvular fibrosa), and a fistulous communication between the left ventricle and left atrium. We present detailed echocardiographic images of these anomalies, which were subsequently confirmed intraoperatively. The patient underwent open heart surgery with pericardial patch repair of the mitral-aortic intervalvular fibrosa aneurysm and fistula.

Bacterial pericarditis is a rapidly progressive and highly fatal infection, and is often diagnosed postmortem in half of the cases. Even with drainage and antibiotics, the mortality rate is high. Gram-positive cocci, specifically Streptococcus penumoniae, have been the most common cause of bacterial pericarditis with a preceding primary site of infection. Following the introduction of antibiotics in the 1940s and more recently the pneumococcal conjugate vaccine, the incidence has drastically decreased.We describe an extremely rare case of primary streptococcus pneumoniae purulent pericarditis that presented with cardiac tamponade. The patient was successfully treated with broad-spectrum antibiotics and urgent pericardiocentesis.Due to the high mortality rate with purulent pericarditis, a high index of suspicion is needed when acute pericarditis is suspected for early diagnosis to instate appropriate therapy with antibiotics and drainage.

Bacterial pericarditis occurs by direct infection during trauma, thoracic surgery, or catheter drainage, by spread from an intrathoracic, myocardial, or subdiaphragmatic focus, and by hematogenous dissemination. The frequent causes are Staphylococcus and Streptococcus (rheumatic pancarditis), Haemophilus, and M. tuberculosis. In AIDS pericarditis, the incidence of bacterial infection is much higher than in the general population, with a high proportion of Mycobacterium avium-intracellulare infection. Purulent pericarditis is the most serious manifestation of bacterial pericarditis, characterized by gross pus in the pericardium or microscopically purulent effusion. It is an acute, fulminant illness with fever in virtually all patients. Chest pain is uncommon. Purulent pericarditis is always fatal if untreated. The mortality rate in treated patients is 40%, and death is mostly due to cardiac tamponade, systemic toxicity, cardiac decompensation, and constriction. Tuberculous infection may present as acute pericarditis, cardiac tamponade, silent (often large) relapsing pericardial effusion, effusive-constrictive pericarditis, toxic symptoms with persistent fever, and acute, subacute, or chronic constriction. The mortality in untreated patients approaches 85%. Urgent pericardial drainage, combined with intravenous antibacterial therapy (e.g. vancomycin 1g twice daily, ceftriaxone 1-2g twice daily, and ciprofloxacin 400 mg/day) is mandatory in purulent pericarditis. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable. The initial treatment of tuberculous pericarditis should include isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day. Prednisone 1-2 mg/kg/day is given for 5-7 days and progressively reduced to discontinuation in 6-8 weeks. Drug sensitivity testing is essential. Pericardiectomy is reserved for recurrent effusions or continued elevation of central venous pressure after 4-6 weeks of antituberculous and corticosteroid therapy.

During the spring and summer of 2001 and in association with the mare reproductive loss syndrome, 22 terminal and 12 clinical cases of equine pericarditis were diagnosed in central Kentucky. Actinobacillus species were the principal isolates from 8 of 10 nontreated, terminally affected and 3 of 10 clinically affected horses. Enterococcus faecalis and Streptococcus zooepidemicus were cultured from the remaining 2 nontreated terminal cases. No viruses were isolated in tissue culture. Nucleic acid of equine herpesvirus-2 was detected in pericardial and tracheal wash fluids of 3 and 1 individuals, respectively. Microscopic alterations in sections of heart and parietal pericardium were consistent with chronic fibrinous bacterial pericarditis. This report confirms a significant role of Actinobacillus species in equine pericarditis and describes an epidemic of this infrequently observed syndrome in the horse.

We report a case of group F streptococcal pericarditis, the source of which was found to be an esophagomediastinal fistula arising from a midesophageal diverticulum. The patient presented subacutely and had no preexisting symptoms of esophageal disease. Antibiotic therapy, surgical drainage, pericardiectomy, and esophageal myotomy led to a successful outcome.

Objectives:Our aim was to review the clinical records from children with large pericardial effusions of inflammatory origin presenting to a tertiary referral centre over the last 21 years, with emphasis on their clinical presentation, management and outcome.Background:The common identifiable causes of pericardial effusion in children include prior cardiac surgery, bacterial pericarditis, malignancy, and connective tissue disorders. In a significant number of children, however, despite extensive investigation, it is not possible to identify a clear aetiology. A viral cause is often considered, though rarely confirmed. The clinical course of such large idiopathic pericardial effusions in children has not been extensively reported.Methods and results:We reviewed retrospectively the records of all patients seen between 1981 and 2001 with large pericardial effusions of inflammatory origin requiring drainage, excluding the effusions related to cardiac surgery or malignancy. We found 31 patients fulfilling our criterions for study. They could be divided into three groups, with 15 patients having no specific identifiable aetiology despite extensive investigation, 12 patients having evidence of bacterial pericarditis, and four with a probable immunologic disorder. Fever was present in only eight patients (53%) in the idiopathic group. All patients in the other groups had fever. Except for fever and the resultant tachycardia, it was not possible to distinguish on clinical grounds, nor on the presence or otherwise of cardiac tamponade, between those with idiopathic aetiology and those with bacterial infection. Of the patients with presumed bacterial pericarditis, five (42%) had both positive blood and pericardial fluid cultures, three (25%) had positive blood cultures, while a further three patients (25%) had only positive pericardial fluid cultures. All patients required drainage of the pericardial effusion, either under echocardiographic guidance or surgically. None of the patients died. The hospital stay was significantly shorter for those with idiopathic as opposed to bacterial pericarditis. Of those with an idiopathic aetiology, six required readmission due to recurrence of the pericardial effusion, with four patients requiring further surgical drainage. No patients required readmission with a bacterial or immunologic aetiology. No patient developed constrictive pericarditis after a median follow-up of 22 months.Conclusion:Patients with large idiopathic pericardial effusion had relatively few constitutional symptoms as compared with their gross echocardiographic findings. Those with bacterial pericarditis had more urgent need for treatment. Patients with pericardial effusion of inflammatory origin, when treated appropriately, had an excellent outcome with no mortality or development of constrictive pericarditis.

We report the case of a 6-month-old male infant with bacterial pericarditis due to Lactobacillus iners. Although the culture of pericardial fluid was negative, L. iners was identified by 16S rRNA gene amplification by polymerase chain reaction and a subsequent sequence analysis. This weakly pathogenic bacterium could develop a severe infection in infants.

The authors report on a cooperative study of 43 cases of bacterial pericarditis observed in children. This disorder was suspected in patients with septicemia who developed symptoms and signs of pericarditis (precordial pain, muffled heart sounds, pericardial friction rub, cardiomegaly). Early diagnosis of this condition is now facilitated by echocardiography. A combination of medical and surgical treatments (appropriate antibiotic therapy after culture and sensitivity tests and early pericardial drainage) led to complete recovery in almost all of the cases (42 of 43). After long-term follow-up, no cases of constrictive pericarditis were observed.

Objective: Purulent pericarditis is a rare disease that is being conventionally managed with intravenous antibiotics and pericardial drainage. In our study, we used intrapericardial fibrinolytic treatment together with pericardiocentesis and antibiotic therapy. We evaluated the role of intrapericardial fibrinolytic treatment in nine purulent pericarditis patients. Methods: Six children and three adult patients with purulent pericarditis, aged between 5 and 50 years, were treated with intrapericardial fibrinolysis by streptokinase. Intrapericardial drainage catheter was placed into the subxyphoidal localization under local anaesthesia and echocardiography guidance, streptokinase was infused into the pericardial sac as the fibrinolytic agent. Results: Repeat echocardiograms showed no reaccumulation of pericardial effusions, pericardial thickening or constrictions. No patients had systemic bleeding, arrhytmias, or hypotension. There was one death which was due to sepsis and congestive heart failure. Conclusion: We believe that early pericardial drainage and intrapericardial fibrinolysis appears to be safe and effective in the treatment of purulent pericarditis. q 2002 Elsevier Science B.V. All rights reserved.

We report a case of pericarditis caused by Salmonella enteritidis phage type 1 without any gastrointestinal symptoms in an otherwise healthy man.

Fig. 4. A, Photograph of heart removed at autopsy after partial pericardiectomy showing extensive fibrinous exudate covering visceral pericardium over entire cardiac surface. B. Higher magnification. Parietal pericardium has been dissected away. procedure (Fig. 2). To our knowledge this phenomenon has not been well described and may represent an unusual feature of purulent fluid drainage influencing the acute inflammatory process. In conclusion, this first description of pericardial infection from S. ugdactiae demonstrates that group B streptococcus can be an important etiologic organism in purulent pericarditis. This observation may be particularly relevant to diabetic individuals with skin infection. Because this patient showed few signs of severe systemic infection, heightened awareness may be necessary to allow early diagnosis and treatment. From this case report the differential etiologic diagnosis of purulent bacterial pericarditis should include group B streptococcus.

A 63-yr-old man developed pericardial effusion with tamponade after transbronchial needle aspiration (TBNA) of a subcarinal mass. A diagnosis of polymicrobial bacterial pericarditis was made when pericardiocentesis revealed purulent fluid that grew a mixed culture of anaerobes and aerobes, organisms that constitute part of the normal upper respiratory tract flora. To examine the possibility that contamination of the transbronchial needle (TBN) could lead to purulent pericarditis by inoculation of bacteria into the mediastinum, quantitative cultures of the TBN content were performed in seven consecutive patients. Abundant growth of multiple anaerobic and aerobic organisms was demonstrated in all seven cultures. We conclude that subcarinal TBNA is another potential cause of purulent pericarditis. This results from upper respiratory tract contamination of the open distal end of the TBN as it passes through the suction channel of the bronchoscope.

We describe two HIV-seropositive patients with acute pneumococcal empyema and pericarditis. Cardiac tamponade evolved rapidly in each patient and was reversed with prompt surgical intervention. In each case, immunologic abnormalities were detected which could have facilitated local spread of infection and progression to tamponade. Pericarditis, an otherwise rare manifestation of pneumococcal infection in the antibiotic era, should be anticipated in HIV-seropositive patients with pneumococcal empyema.

Infectious complications occurring after percutaneous transluminal coronary angioplasty are uncommon. We are reporting a case of bacterial pericarditis developing 1 week after coronary angioplasty and stent implantation. Treatment with appropriate antibiotics and drainage of the infected pericardial effusion was followed by a protracted hospital course and eventual control of infection and discharge of the patient.

Purulent pericarditis, though rare in developed countries, is not uncommon in developing countries. However, the type of pericardial drainage required and the risk of subsequent constrictive pericarditis has not been clearly defined. Thirty children between the ages of 3 months and 12 years with a diagnosis of purulent pericarditis were studied retrospectively. Pericardial effusion was confirmed in all by echocardiography and the diagnosis of bacterial pericarditis was based on aspiration of purulent fluid with leucocytosis and high proteins. Purulent pericarditis was a part of the disseminated sepsis in 25 (83%) children. Fever was present in all, hepatomegaly in 28 and breathlessness in 25, whereas muffled heart sounds, raised JVP and pericardial rub were found in only 18, 16 and 7, respectively. The ECG was abnormal in only 16 children. Staphylococcus aureus was the causative organism in 24 (96%). Open surgical drainage was done in 26 children, 23 of whom underwent anterior pericardiectomy. Two children died of disseminated sepsis. None of the 21 who returned for follow-up for periods of between 4 and 24 months had any long-term sequelae.

Bacterial pericarditis with cardiac tamponade is a life-threatening disorder that has been associated with a variety of organisms. There is usually an associated underlying condition or a seeding of the pericardium from an infection elsewhere. We report the development of cardiac tamponade and a subsequent pericardial constriction due to group F streptococcus purulent pericarditis. We believe this to be the first report of a postpartum patient with purulent pericarditis.

Hemorrhagic pericardial effusion is known to occur due to tuberculosis, malignancy, uremia or trauma. We present a rare case of a 6 year old girl with bacterial pericarditis who had hemorrhagic pericardial effusion with cardiac tamponade.

An 85-year-old male visited our hospital because of dyspnea. Chest radiography showed marked cardiomegaly and pneumonic infiltration. Transthoracic echocardiography showed moderate pericardial effusion, which resulted in effusive constrictive pericarditis and severe left ventricular systolic dysfunction. During the hospital course, the patient developed cardiogenic shock and was treated with an inotropic agent and intra-aortic balloon pump. The patient’s vital signs were stabilized after pericardiocentesis and drainage. A yellowish purulent pericardial effusion was drained and Streptococcus pneumoniae was isolated. Bacterial purulent pericarditis was not uncommon before the antibiotics era, but it is extremely rare nowadays. Here, we report a case of purulent bacterial pericarditis presenting with severe left ventricular systolic dysfunction and cardiac tamponade. (Korean J Med 2012;82:221-226)

Pericardioscopy is a new diagnostic tool for macroscopic visualization of alterations in both the epicardium and pericardium. We report on 35 patients with pericardial effusion due to inflammatory perimyocardial disease. After puncture of the pericardial effusion, an 8F sheath was introduced over a guidewire under X-ray control. The pericardial pressures were measured; the fluid was removed by aspiration and exchanged with 100 ml of body-warm saline until the pericardial fluid was clear. To visualize the peri- and epicardium, for video- and photo documentation, two sorts of 8F endoscope were used, either a flexible fibreglass version or a rigid 110 degree one--both made by Storz. Cytology of the fluid and optically guided and controlled epicardial and pericardial biopsies were performed to classify the form of pericarditis. A specific diagnosis of viral pericarditis could thus be established in seven cases--by in situ hybridization for cytomegalovirus (n = 3) and by microneutralization test for enteroviruses and/or coxsackievirus B4 isolation (n = 4); of lymphocytic perimyocarditis in 16; of bacterial pericarditis in seven and antibody-mediated autoreactive pericarditis in five cases.

Pseudomediastinal mass as a result of bacterial pericarditis is a rare clinical presentation. We report one such case in a patient with end-stage renal disease receiving hemodialysis, who presented primarily with manifestations of right heart compression due to a large encapsulated pericardial abscess and, surprisingly, with no overt signs of sepsis. Surgical drainage, pericardiectomy, and antibiotic therapy led to a successful outcome.

The indication for pericardiectomy is unequivocal in moderate or severe chronic constrictive pericarditis. Constrictive pericarditis has been the basic indication for pericardiectomy for more than fifty years. However, constrictive pericarditis is the common end stage of a variety of pericardial diseases and, in many cases, it implies a course of many years. As in other heart diseases in which early operation has gained ground, one might wonder whether in pericardial diseases resection of the pericardium would not be indicated before constriction develops or becomes severe. One might also wonder whether pericardiectomy might not also be indicated to treat non constrictive cases with an unfavorable course such as severe tamponade, bacterial pericarditis or recurrent pericarditis. A critical assessment of these types of indication is made in the present chapter.

Summary Acute purulent pericarditis caused by Haemophilus influenzae is unusual especially in children. In recorded cases, respiratory symptoms are present and children under 4 years of age are most often affected. The authors report a case of pericarditis caused by H. influenzae in an 8 month-old child, associated with meningitis. Early recognition and rapid diagnosis associated with aggressive medical and surgical therapy were successful.

Three male patients with purulent pericarditis, in whom complete drainage could not be obtained by pericardiocentesis, were treated with transcatheter intrapericardial urokinase to prevent the development of chronic constrictive pericarditis. As shown by echocardiography, the intrapericardial fibrin layers disappeared in two cases and were reduced by more than half in the third. Effects on systemic coagulation indices and complications related to intrapericardial lysis were not observed.

Serious infections caused by Staphylococcus aureus in HIV-infected patients have been reported. Contributing factors in the development of invasive S aureus infections include a high rate of skin and nasal colonization, frequent dermatologic disease, and the use of intravenous catheters. The authors report three cases of S aureus pericarditis in HIV-infected patients. While cases of viral, mycobacterial, and malignant pericardial effusions in HIV-infected patients have been reported, a review of the literature disclosed only three cases of bacterial pericarditis. Despite appropriate antibiotic therapy and drainage, a patient's condition may abruptly deteriorate and progress to tamponade. Early recognition of bacteremia and pericarditis and monitoring for cardiac tamponade, along with aggressive treatment, can result in a favorable outcome, but mortality remains high, particularly when S aureus is the causative agent.

Cures of Candida pericarditis reported in the literature uniformly involved surgical drainage of the pericardial space. We report a patient with purulent pericarditis caused by Candida albicans who was treated successfully with antifungal chemotherapy combined with a single pericardiocentesis that did not completely evacuate the pericardial space. This case indicates that thoracotomy with surgical drainage of the pericardium is not mandatory for successful therapy of Candida pericarditis.

The authors report a patient with diffuse pyogenic pericarditis and focal myoendocarditis initially detected using In-111 WBC scintigraphy. The patient was in septic shock after hemodialysis for the treatment of chronic renal failure. This was preceded by clinical signs and symptoms of pericarditis thought to be viral in nature. Initial investigations found no septic focus, and the patient was referred for In-111 WBC scintigraphy. This revealed a striking "halo" of increased activity around the heart, strongly suggesting bacterial pericarditis. A subsequent pericardiocentesis yielded 400 ml of purulent material, confirming the diagnosis.

Transient cardiac constriction is an unusual complication of purulent pericarditis. It should be suspected in the presence of clinical and haemodynamic deterioration when signs of activity have abated. Features of cardiac constriction were observed in a 4-year-old boy 2 weeks after surgical drainage. The patient was managed conservatively without surgery and the outcome was good. Follow up 2 years later showed a healthy boy with a normal cardiological examination.

Bacterial pericarditis is commonly a disease of children for which the primary treatment is surgical drainage. We report the case of a 19-yr-old patient presenting with pneumococcal pericarditis and tamponade treated successfully with intrapericardial catheter drainage and intravenous antibiotics. The technical aspects are discussed.

A patient is described in whom the diagnosis of purulent pericarditis was made by chest radiograph because of the presence of air with a fluid level within the pericardial cavity and was confirmed subsequently at surgery.