Pseudomonas pericarditis in an immunocompetent newborn: unusual presentation with review of the literature

Pseudomonas aeruginosa-related effusive-constrictive pericarditis diagnosed with echocardiography: A case report

BACKGROUND

Effusive-constrictive pericarditis (ECP) is an uncommon pericardial syndrome. Careful echocardiographic examination may provide helpful information not only for diagnosing but also for managing ECP. ECP has various etiologies; however, Pseudomonas aeruginosa (P. aeruginosa) infection has not been reported as a cause to date. Herein, we present a rare case of ECP caused by P. aeruginosa infection, which was followed up using echocardiography.

CASE SUMMARY

A 30-year-old man was admitted to our hospital with a 2-mo history of cough, dyspnea, bloating, palpitations, and lower-extremity edema. The patient was initially diagnosed with pericardial effusion by transthoracic echocardiography. Drainage of pericardial effusion was performed to relieve the clinical symptoms. A follow-up echocardiogram showed that the pericardial effusion had decreased; however, the right atrial pressure continued to increase, and signs of constrictive pericarditis were observed upon a more comprehensive inspection. Therefore, the diagnosis of ECP was established based on the comprehensive pre- and post-pericardiocentesis echocardiographic findings. An urgent pericardectomy was subsequently performed, which significantly relieved the patient's clinical symptoms, and the signs of pericardial constriction on echocardiography improved. Pericardial effusion and pericardial culture showed growth of P. aeruginosa.

CONCLUSION

ECP induced by P. aeruginosa infection remains a rare disease. The presence of echocardiographic features of constrictive pericarditis after pericardiocentesis therapy is highly indicative of ECP.

Bacterial pericarditis: diagnosis and management

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.

The value of a CT-guided fine needle aspirate in infants with lung abscess

OBJECTIVE

To describe the range of pathogens isolated from a lung abscess in infants less than one year of age. To assess the role of direct culture from the abscess.

METHODS

The two index cases were managed in 2002. An institution-based review was conducted of all infants up to one year of age diagnosed with a lung abscess between 1989 and 2002. Data sources were hospital's disease index and Neonatal Intensive Care Unit Audit database using ICD9 and ICD10 diagnostic codes for 'lung abscess'.

RESULTS

Five infants, under the age of one year, were treated for a lung abscess. In the one case where the abscess was left-sided it was associated with a congenital cystic adenomatoid malformation of the lung. Pathogens were isolated following direct culture of the abscess in four cases. In three cases a single pathogen was isolated: pseudomonas aeruginosa, staphylococcus aureus and haemophilus influenzae. In one case a mixture of escherichia coli, streptococcus milleri and an anaerobe, propionibacteria, were cultured. Antibiotic therapy was directed at the identified pathogen(s) in all four cases. There was no mortality or recurrence.

CONCLUSION

Predisposing factors for a lung abscess in infancy include prematurity, assisted ventilation, congenital lung anomaly and aspiration. Given the range of potential pathogens, direct culture by CT-guided fine needle aspiration is recommended to direct appropriate intravenous medical therapy provided the abscess is located peripherally.