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Publication Date



oregon; portland; ppmc


Internal Medicine



Purulent pericarditis is a localized purulent infection in the pericardial space •Before the era of antibiotics, purulent pericarditis was related to complications of pneumococcal pneumonia. Now more frequently associated with thoracic surgeries, immunocompromised hosts and nosocomial blood infections.1 •This case is an unusual presentation of acute methicillin-resistant staphylococcus aureus (MRSA) purulent pericarditis with a course complicated by cardiac tamponade, opiate withdrawal, and a right ventricle (RV) laceration.

Case Presentation

History of Present Illness •Patient is a 30-year-old M active intravenous drug use (IDU) with a recent history of MRSA bacteremia, endocarditis, parasternal abscess s/p I&D, and sternal osteomyelitis with inadequate treatment duration presenting to the emergency room with 3 days of worsening pleuritic chest pain and dyspnea. Physical Exam •Physical exam notable for tachycardia, low grade fever, and decreased breath sounds. No peri-sternal tenderness. Initial Diagnostic Workup •Chest radiograph withgroundglassconcerning forseptic emboli •Computerized tomography (CT) of the chest showed nodules, anteriorsternal thickening, but no evidence ofosteomyelitis. •Preliminary blood culturespending •IV vancomycin treatment was started for presumptive recurrent tricuspid valve (TV) endocarditis with septic emboli.

Hospital Course

• Patient remained tachycardic with pleuritic pain in the setting of active heroin withdrawal. • Two days after admission, preliminaryblood cultures continued to have no growth,he became hypotensive with anuptrendingleukocytosis, prompting further evaluation. • Electrocardiogram (EKG) with marked diffuse STelevations consistent with pericarditis. • Transthoracic echocardiogram remarkable for a large fibrinous pericardial effusion.

Further Complications

Pericardiocentesis wasattempted and the catheter was placed in the RV, which led toa RVrepair, subtotal phrenic to phrenic pericardiectomy and mediastinalwashout. •During the surgery frank pus was visualized in the pericardialsac. •Pericardial fluid andtissue cultures were positive for MRSA. •Hisblood cultures remained negative. Thepatient did well in thepostoperative setting and his mediastinitis was treatedwithIV vancomycin for a total of 4 weeks.

Learning Points

• Patients with purulent pericarditis generally have non-specific symptoms, so diagnosis relies on high clinical suspicion and a pericardiocentesis for pericardial fluid analysis. •The most common organism responsible for purulent pericarditis is Staphylococcus aureus.2 •Mortality rate approaches 20-30%3 making early treatment with targeted antibiotics and aggressive pericardial drainage paramount in improving patient outcomes. •Clinicians should be aware of their cognitive biases during clinical decision making, as it can be crucial for diagnosing conditions like purulent pericarditis.


Internal Medicine


Graduate Medical Education

Conference / Event Name

Academic Achievement Day, 2021


Providence Portland Medical Center

The Peculiar Case of Purulent Pericarditis