Presentation
Pain and swelling to the left chest wall after lifting. Exertional shortness of breath. Background of intravenous drug abuse. Examination revealed peripheral edema. ECG - low voltage QRS.
Patient Data
CXR showing extrapleural opacification in the left upper zone and enlarged cardiac silhouette with a globular contour suggestive of pericardial effusion.
Also bi-basal atelectasis and consolidation and small bi-basal pleural collections.
Very large low-density pericardial effusion measuring up to 3.9 cm in depth.
A lobulated fluid collection is seen deep to the left pectoralis major which extends into the extrapleural/pleural space of the left apex as well as the left axilla. There are multiple small locules of gas within this collection, in close proximity to the costochondral joint of the first rib which has a slightly irregular appearance.
A 5.7cm filling defect is seen within the left brachiocephalic vein which appears to extend into the subclavian and brachial veins. There is poor opacification of the left internal jugular vein.
Small bilateral pleural effusions with associated passive atelectasis.
Normal appearance of the tracheobronchial tree.
Prominent lymph nodes within the left superior mediastinum, possibly reactive in nature.
Ascites within the visualized abdomen.
Case Discussion
Purulent pericarditis is an infection in the pericardial space producing purulent fluid1. It was historically a complication of pneumococcal pneumonia. In the modern antibiotic era, it is rare 2 and also due to a bloodstream infection.
It is more common with predisposing factors including recent thoracic surgery, chest trauma, chronic renal failure, malignancy, alcohol abuse and pre-existing pericardial disease 2,3.
Direct spread can result from virtually any organism but the most common is Streptococcus pneumoniae. Hematogenous spread is most common with S. aureus and Strep spp. Spread from infective endocarditis is possible. Perforating injury or surgery is also a possible source of infection. S. aureus is the most common pathogen overall2. The usual presentation consists of high fever, tachycardia, cough, and chest pain.
This patient had disseminated MRSA infection including purulent pericarditis and empyema. He had clinical signs and symptoms suggestive of pericardial effusion and early tamponade. The effusion was drained but reaccumulated and the patient underwent pericardiectomy and completed several weeks of intravenous antibiotics.
As identified on the CT, he had left internal jugular thrombosis. He was also found to have left 1st costochondral junction osteomyelitis.
This case shows the unusual fashion in which purulent pericarditis presents but also highlights the unusual presentations of IVDU patients who often have serious pathology presenting in a less overt manner.
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