Purulent pericarditis caused by group G streptococcus

Milk of calcium pericardial effusion confirmed with postmortem computed tomography and autopsy findings: A case report

We present the postmortem computed tomography and autopsy findings of a 60-year-old man who developed milk of calcium pericardial effusion and died of constrictive epicarditis. He experienced out-of-hospital cardiopulmonary arrest, and spontaneous circulation returned at the hospital. However, 7 h after recovery, the patient died. He had a swollen neck, had been experiencing coughing from 4 to 5 days earlier, and had no significant medical or surgical history. On computed tomography (CT), highly dense pericardial fluid (CT value: 130-150 Hounsfield units) and multiple calcifications along the epicardium and pericardium were visualized. The epicardium and pericardium were thick, hard, rough, and widely calcified with mild adhesions on autopsy. The pericardial cavity contained a pale, reddish brown, turbid, and highly viscous liquid. Bacteriological tests of pericardial fluid cultures revealed the presence of group G β-hemolytic streptococci. Hence, we diagnosed the patient's cause of death as heart failure due to constrictive epicarditis. We believe that this case of milk of calcium pericardial effusion is the first case confirmed with postmortem CT and autopsy findings.

Comparative studies on streptococci of serological group G isolated from various origins

The streptococcal cultures used in the present study were isolated from dogs, bovines and humans and could be classified into Lancefield's serological group G. Most of the group G streptococci grew in fluid media as granular sediment with clear supernatant and formed compact colonies in soft agar. The majority of the group G streptococci from dogs and bovines displayed CAMP-like synergistic haemolytic activities on sheep blood agar, fermented lactose and salicin and produced the enzyme alpha-D-galactosidase. The group G streptococci from humans mainly fermented trehalose and produced the enzyme beta-D-glucuronidase. In addition, some of the group G streptococci reacted with type antigen X and R and two cultures with M6 specific antiserum. A positive opacity factor reaction could be observed with few group G streptococci isolated from dogs and bovines, but not with those from humans. In binding studies with 125I-labelled plasma proteins most of the cultures interacted with 125I-immunoglobulin G and 125I-albumin. Binding of 125I-IgG was more pronounced among group G streptococci isolated from humans. The determination of antibiotic susceptibility revealed that most of the group G streptococci were susceptible to bacitracin, cefoxitin, clindamycin, erythromycin, gentamicin, penicillin and sulfamethoxazole-trimethoprim. Some of the cultures were resistant to minocycline, neomycin and tetracycline. All this data clearly distinguished group G streptococci isolated from animals and humans and could additionally be used for individual characterization of this microorganism. This might be useful in epidemiological aspects and contribute to understanding infections caused by these bacteria.

Diagnosis and management of pericardial abscess in trauma patients

Pericardial infection is an uncommon clinical entity after traumatic injury. Although invasive intervention is rarely necessary for mild pericardial inflammation, pericardial abscess can be life-threatening. The charts of 27 patients with pericarditis requiring management in the intensive care unit and/or invasive intervention at Harborview Medical Center during a 10-year period were reviewed. Six cases of trauma-related pericarditis were identified, including three cases of pericardial abscess following torso trauma without initial cardiac or pericardial injury. Pericardial abscess following trauma was associated with the sepsis syndrome and multiple system organ failure (MSOF) in all patients. Computed tomography and pericardiocentesis were useful diagnostic adjuncts. All patients required thoracotomy for pericardial drainage and pericardiectomy. Successful surgical management of pericardial abscess contributed to the resolution of sepsis, multiple end-organ dysfunction and, ultimately, patient survival in all cases. We conclude that pericardial abscess, although rare, should be considered a potential occult site of sepsis capable of driving MSOF in trauma patients. Expedient diagnosis and surgical drainage are essential for successful patient outcome.