Postgraduate Medical Journal (1989) 65, 444 - 448

Review Article

Purulent pericarditis
I.P. Hall

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Department of Physiology and Pharmacology, Medical School, Queen's Medical Centre, Nottingham NG7 2UH,
UK.

Summary: Purulent pericarditis is an infrequent, but important complication of infective illnesses, in

particular pneumonia, which if diagnosed early has a good prognosis. The incidence of the condition is
probably increasing, particularly in the immuno-compromised group ofpatients. 'Classical' symptoms and
signs are often absent, and a high index of awareness is required to diagnose the condition. This review
deals with the epidemiology, microbiology, clinical features, treatment and prognosis of purulent
pericarditis with two illustrative examples of typical cases.

Introduction Illustrative cases

Bacterial infection of the pericardial cavity was first Case one
described by Galen,' and in the intervening centuries
before the advent of antibiotic therapy, was an A 60 year old woman was admitted with a 7-day
infrequent but well recognized complication of infec- history of increasing cough, dyspnoea, right pleuritic
tions such as pneumococcal pneumonia or chest pain and malaise. On examination, she was
staphylococcal osteomyelitis. After the development unwell, pyrexial at 38.5°C and had signs of right lower
of broad spectrum antibiotic treatment for infections, and middle lobe consolidation. Investigations re-
the incidence declined rapidly2 but, more recently, the vealed a leucocytosis and mild hypoxia. An electrocar-
condition seems to be increasing again. However, diogram showed anterior T wave inversion and her
many of the recently reported cases have occurred in chest X-ray revealed a large heart with consolidation
either immuno-compromised individuals, or in indi- in the right middle and lower lobes and the lingula. She
viduals with underlying disease affecting the pericar- was treated with antibiotics and nebulised bron-
dial cavity2 and, as the number of these patients chodilators. The following day she became more
increases, the incidence of purulent pericarditis is dyspnoeic and developed signs of cardiac tamponade.
likely to continue to rise. The spectrum of causative Echocardiography revealed a large pericardial
organisms has also altered markedly as the population effusion and pericardiocentesis yielded 600 ml of thick
at risk has changed.2 It is an important condition to be pus, microscopy of which showed numerous Strep-
aware of, as early appropriate treatment is associated tococcuspneumoniae. Treatment was changed to intra-
with a good prognosis.3 In most published series, venous benzyl penicillin 8 g/day and she gradually
however, the diagnosis was only made in many of the improved over the course of the next 10 days. Subse-
cases at post-mortem. Despite the development of quently, bilateral empyema developed and were
modern investigative procedures such as echocardio- drained. Echocardiograms over this period showed
graphy, ante-mortem diagnostic rates have improved gradual reaccumulation ofthe pericardial effusion and
little over the years. This review describes the 9 days later evidence of cardiac tamponade reap-
epidemiology, aetiology, clinical presentation and peared. A pericardial drain, inserted under general
management of the condition, with two illustrative anaesthetic, then drained up to 100 ml of pus a day,
cases to show the spectrum of the disease. which gradually reduced. The drain was removed after
4 weeks and she was discharged. At follow-up she
remained well.
Case two
Correspondence: I.P. Hall, B.A. (Oxon), B.M., B.Ch.
(Oxon), M.R.C.P. (UK). A 68 year old man was admitted with a 3-day history
Accepted: 14 February 1989 of fever, myalgia, dyspnoea and left pleuritic chest
D The Fellowship of Postgraduate Medicine, 1989
 PURULENT PERICARDITIS 445

pain. Four years earlier, a diagnosis of non-Hodgkin's Organisms causing purulent pericarditis
lymphoma had been made on lymph node biopsy and
he had received chlorambucil for one year. Six months The organisms most frequently causing purulent
before admission, chlorambucil was recommenced at pericarditis are staphylococcus, streptococcus and
15 mg a day following the reappearance of lympha- Gram-negative organisms such as proteus, Escherichia
denopathy but was stopped 3 weeks before admission coli, pseudomonas and klebsiella. In a series of
because of neutropenia. On admission, he looked microbiological isolates from 53 cases of purulent
unwell and was pyrexial at 38.8°C but there were no pericarditis, the latter group accounted for 32% of all

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localizing focal signs ofinfection. Empirical treatment isolates, with 22% being due to staphylococcus and
with antibiotics was commenced. Twenty four hours 22% being streptococcus, with Streptococcus pneu-
later, his jugular venous pressure was elevated 6 cm moniae accounting for a little under half of this
with a tachycardia of 140 (atrial flutter with 2: 1 block). subgroup. Salmonella sp., Shigella sp. and Neisseria
Later that day he deteriorated further and there was meningitidis were the other most frequently isolated
30 mm of paradox. Chest X-ray revealed an increased organisms.2 Many organisms have been reported to
cardiac diameter and echocardiography showed a cause purulent pericarditis on rare occasions, partic-
large pericardial effusion. Pericardiocentesis obtained ularly in the immuno-compromised. A comprehensive
750 ml of turbid fluid, which contained numerous list is given in Table I.
Staphylococcus aureus. Intravenous flucloxacillin was A review of tuberculous pericarditis can be found
given and over the next week, he improved rapidly elsewhere.8
with no recurrent clinical signs of cardiac tamponade. Neisseria meningitidis, which accounts for about 3%
Repeat echocardiography revealed no reaccumulation of all cases of purulent pericarditis,3'7 usually causes
of fluid. At 3 months follow-up he remained well. pericarditis after meningococcaemia in patients with
meningitis. Usually the Group C N. meningitidis is the
causative organism.9 Culture of pericardial fluid is
often sterile. However, several cases of pericarditis in
the absence of clinically apparent meningococcaemia
Epidemiology have been reported.'0"'
In Boyle's review of 415 cases of purulent pericar-
In the largest recent single series of patients from the ditis, 2% were caused by Haemophilus influenzae.7 All
USA, purulent pericarditis occurred most frequently of these cases were in children aged under 6. There
in children and in the fifth decade,2 although cases have, however, been isolated cases reported in adults.'2
occurred in all age groups. In the developing world, it Legionella species have also been reported to cause
is a not infrequent sequela of severe infection (partic- pericarditis on rare occasions.'5"6 In one case, two
ularly due to Staphylococcus aureus or Streptococcus separate species were cultured in a single pericardial
pneumoniae) in children.4-6 aspirate.'6 Similarly, in purulent pericarditis due to
Before 1940, male cases outnumbered female cases Gram-negative organisms, multiple organisms are
by 4: 1,' but since then the sex incidence has changed frequently found.2
such that it is now about equal.2 In the Johns Hopkins' Fungi and protozoa are occasional, but increasingly
series of 200 patients between 1900 and 1975, 86% of seen, causes of purulent pericarditis, almost invariably
cases occurring in the years before antibiotic therapy
became widespread were considered to be a complica- Table I Rare causes of purulent pericarditis
tion of primary infection elsewhere in the body,
whereas 78% of subsequent cases occurred in patients (a) Bacterial
with an underlying condition predisposing them to Actinobacillus'7"18
infection.2 This latter group included patients with Legionella'5"6
pre-existing pericardial effusions due to chronic condi- Haemophilus influenzae7"2-14
tions such as renal failure, the immuno-compromised, Eikenellal9
and people who had received penetrating chest wall Francisella tularensis7
injuries or who had undergone cardiac surgery. The (b) Non-bacterial
commonest initial infections in the first group were Histoplasma20
pneumonia, osteomyelitis, meningitis, otitis media Blastomyces21
and skin infections, and the causative organism was Coccidioides22
hence most frequently a staphylococcus or streptococ- Aspergillus23
cus. However, with many recent cases occurring in the
Candida24
immuno-compromised, and involving antibiotic resis- Toxoplasma25
Nocardia3 26'27
tant organisms, Gram-negative and other atypical Entamoeba28
organisms are increasingly being implicated.
446 I.P. HALL

in immuno-compromised individuals.3 In such localizing signs (as in Case 2) provide a greater

patients, myocardial involvement by fungus usually diagnostic problem needing a high index of awareness
precedes the development of pericarditis. The most of this condition such that echocardiography is
frequent organisms to be involved are candida, 324 arranged early in the course of the disease. The
aspergillus3'23 and nocardia.3,26,27 diagnosis is particularly difficult in the immuno-
compromised, who may lack fever (and leucocytosis)
and have atypical organisms with more indolent
Symptoms and signs of purulent pericarditis presentation, and in children. In the latter,

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hepatomegaly, which was present in all eleven cases in
Purulent pericarditis presents as an acute febrile one series of bacterial pericarditis in children aged
illness. However, the low ante-mortem diagnosis rate under 16 years,6 is a useful clinical sign. The
is evidence of the lack of definitive localizing symp- differential diagnosis in the adult age group includes
toms and signs in the disease. In addition, the presence all causes of pericardial effusions with co-existent
of co-existent infection, which is usually the source of non-cardiac infection, fulminant systemic lupus
the organisms causing pericarditis, may mask the erythematosus, empyema, acute myocardial infarc-
underlying symptoms and signs of purulent pericar- tion, and malignancy.30
ditis. A list of the major clinical features of the disease
and their frequency of occurrence in 68 cases taken
from a group of series reported in the English language Investigations
publications since 1945 is given in Table II.3,6,7,29,31 The
commonest co-existent infections in these cases were The advent of echocardiography has greatly improved
pneumonia (particularly pneumococcal), otitis media, the ability to diagnose pericardial collections
meningitis (particularly meningococcal), skin infec- accurately. In all the cases reviewed in which the
tion and staphylococcal osteomyelitis and subdiaph- diagnosis was not established ante-mortem, echo-
ragmatic abscesses. As clinical details are not available cardiography had not been performed. In the occas-
for every feature in all case reports, the frequency of ional patient with inadequate ultrasound windows to
occurrence of each feature is given as a percentage as allow echocardiography to be performed, computer-
well as absolute figures. Because there is a tendency to ized tomography provides adequate imaging.3'
report series of cases with unusual pathogens or with Table III lists the frequency of abnormal investiga-
pericarditis in association with other medical condi- tions in patients with purulent pericarditis (sources as
tions, there is inevitably some reporter bias in the cases Table II). Leucocytosis and tachycardia on a 12 lead
reviewed. Several interesting points, however, still electrocardiogram were, not surprisingly, present in
emerge. all patients. ST changes (generally non-specific T wave
With regard to symptoms, most patients were changes) were also present in 71 % of cases, although
febrile and many dyspnoeic, but only a half had had only 23% had 'classical' ST elevation. The other point
chest pain at presentation. The most striking point, to note is that although increased cardiac diameter on
however, is the absence of 'classical' signs such as chest X-ray was present in 73% of cases, it was
elevated central venous pressure or pulsus paradoxus significantly absent in the rest, some of whom had
in nearly half the cases. Hence, whereas the patient subsequently positive echocardiographic examina-
presenting with lobar pneumonia who then develops
cardiac tamponade provides a relatively easy diagnos- Table III Abnormal investigations in 68 cases of purulent
tic challenge (as in Case 1), those presenting without pericarditiS36,'7,29'3'
Table II Symptoms and signs in 68
Number Frequency
cases of purulent of cases (%)
pericarditiS3'6,7,29'3l

Number of cases Frequency (%)

Leucocytosis* 34 100
Tachycardia on 12 lead ECG 33 100
Fever 64
Pericardial collection at 13 100
88 echocardiography
Dyspnoea 33 61 Exudative pericardial effusion 15 93
Chest pain 51 57 Increased cardiac size on CXR 48 73
Pulsus paradoxus 49 65 ST changes (including ST 34 71
Hepatomegaly 58 59 elevation) on 12 lead ECG
Elevated central venous 59 58 Pleural effusion on CXR 46 46
pressure ST elevation on 12 lead ECG 30 23
Pericardial friction rub 46 46
Ascites 31 19 *Excluding cases in neutropenic patients.
CXR = chest X-ray.
 PURULENT PERICARDITIS 447

tions. Although small, localized pericardial collections established at an early stage, appropriate management
may be missed by echocardiography, there is nonethe- instigated, and no serious underlying disease exists,
less a strong argument in favour of making echocar- the prognosis should be excellent.3'6'7
diography a mandatory investigation in the febrile
patient with no localizing signs.
Once the diagnosis is suspected, pericardiocentesis Purulent pericarditis in the immuno-compromised
usually proves necessary, either to relieve cardiac
tamponade or to provide a microbiological diag- Establishing the diagnosis of purulent pericarditis in

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nosis.29 As well as culture of the aspirate, counterim- the immuno-compromised, in whom localizing signs
munoelectrophoresis may provide a clue to the of infection and leucocytosis may be absent, and in
causative organisms by revealing the presence of whom atypical organisms are more likely to occur,
antigen in cases of pneumococcal,31 meningococcal,32 presents a particular challenge. This problem will
or Haemophilus influenzae33 pericarditis. Low glucose increase as the number of patients at risk increases
levels and high lactic dehydrogenase levels have been with greater use of immunosuppressive drugs, and as
recorded in pericardial aspirates from patients with the population of patients with acquired immune
purulent pericarditis,3 whilst the effusion, as expected, deficiency syndrome (AIDS) increases. A case of
normally contains neutrophils and is an exudate. staphylococcal pericarditis has already been reported
Separate specimens should be sent for culture for in a patient with the AIDS-related complex.3 To make
Mycobacterium tuberculosum. Cytology should also the diagnosis in such patients, it is necessary to have a
be performed on the pericardial fluid to exclude an high index of suspicion, and to arrange early echocar-
underlying malignancy involving the pericardium with diography. The diagnosis in the AIDS group of
infection of an associated effusion. patients is complicated by the occurrence of recurrent
aseptic pericardial effusions in this condition35 with the
result that pericardial infection in such individuals can
Management and prognosis only be diagnosed by pericardiocentesis.
Following pericardiocentesis, treatment should con-
sist of an appropriate antimicrobial agent for at least 4 Conclusions
weeks29 and, if re-accumulation of pericardial fluid
occurs, surgical drainage using a wide bore pericardial Purulent pericarditis is an infrequent, but important
drain inserted through a pericardial window.29 This is complication of pneumonia and other infective ill-
frequently necessary (as in Case 1) to prevent recurrent nesses which may be increasing in frequency, partic-
tamponade and to avoid the risks of repeated pericar- ularly in the immuno-compromised group of patients.
diocentesis. Total pericardectomy has also been used 'Classical' symptoms and signs are often absent (par-
in some patients29 but is not usually necessary. ticularly in the immuno-compromised) so a high index
The early complications of purulent pericarditis, of awareness of the condition is necessary. Echocar-
other than recurrent tamponade, include the develop- diography followed by pericardiocentesis are the
ment of mycotic aneurysms and local spread of investigations of choice. If the diagnosis is established
infection to involve the myocardium.2 The main late early, the prognosis is excellent following appropriate
complication is of pericardial constriction' which, treatment, which should consist of antibiotics and
however, has been only rarely reported. The prognosis surgical intervention if necessary.
of the condition depends upon the timing of diagnosis,
and the prognosis of any underlying disease also
present. The variable mortality rates reported in Acknowledgements
different series are a reflection of the different patient
groups being described. Overall, in cases since 1943, I am grateful for helpful advice in preparing this review from
recovery occurred in 60% of the patients in the series Dr I.D.A. Johnston, and for permission to report Case 2
included in this review. However, if the diagnosis is from Professor J. Hampton.

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