ACUTE
STAPHYLOCOCCAL
PERICARDITIS
By Jeanne M. Horan, M.D.
Department of Pediatrics, School of Medicine, Tulane University and Charity HoitaZ of LouLnlana
(Submitted February 6, accepted June 28, 1956.)
ADDRESS: 1430 Tulane Avenue, New Orleans 12, LouIsiana.
38
E
ARLIER writers on acute bacterialpen-carditis describe it as an easily missed
complication of preceding infection.1 The
commonest agent was the pneumococcus;
and the most frequent preceding disease,
pneumonia and empyema.27 The mortality
rate was almost 100% if medical treatment
was followed. Pericardiostomy, however,
improved the prognosis, and about half the
patients survived.8b0 Staphylococcal
pen-carditis was particularly noted during acute
osteomyelitis.” It carried an even poorer
prognosis (about two-thirds of the patients
died), especially if there was manifest
septi-cemia.8 The organism, extent of associated
infection, and use of open penicandiostomy
were thus the main factors governing
prog-nosis.
Two recent cases of pericarditis due to
staphylococcus (Micrococcus pyogenes)
provided problems in management which
led us to review our experience with this
disease and to compare the present
prog-nosis with that in previous years. One of
these, reviewed here in some detail,
illus-trates the many problems involved in
diag-nosis and treatment.
History
CASE REPORT
J.M.B. (Case 13, Table II): The patient, a
Negro female of 13 months, was admitted to
Charity Hospital, New Orleans, because of
fe-ver and swelling of the left leg. She had been
well until 4 days earlier when she developed
fever and anorexia. Three days before
admis-sion she had been seen in the admitting room
where bronchopnenmonia was suspected and
daily injections of penicillin were instituted.
When fever and dyspnea increased, and
swell-ing of the left leg was noticed, she was admitted to the hospital.
Physical Findings
She was acutely ill. Temperature 40.5#{176}C;
pulse, 140; respirations, 60; blood pressure,
90/60. There was injection of tympanic
mem-branes and pharynx, cardiomegaly, transient
apical gallop rhythm, moist inspiratory rales
in the right lower lung field, and a friction
rub over the left chest which was thought to
be pleural in origin. The liver edge was felt
2 cm below the right costal margin, and the
left leg was hot and swollen from knee to
ankle with an area of fluctuation laterally
below the knee.
Laboratory Findings
Hemoglobin 9 gm/100 ml, hematocrit 29,
sedimentation rate 60 mm/br, leukocytes
11,600/mm3, polymorphonucleir cells 49%.
Urinalysis: pH acid, albumin 3+, sugar 0,
mi-croscopic sediment, negative. Cerebrospinal
fluid, electrocardiogram and tuberculin test
negative. Staphylococcus aureus, cultured from
l)lOod and from the fluctuant area below the
knee, was sensitive to 0.5 unit penicillin,
erythromycin and oxytetracydine. Treatment
consisted of incision of the fluctuant area, peni-cillin and oxytetracycline, and digitalization.
Course
On the eighth hospital day, the heart tones
were noted to be muffled, there was a
para-doxical pulse, and the liver was enlarging.
The electrocardiogram showed low T waves.
A pericardial tap yielded 40 ml of
sero-sanguinous fluid containing many leukocytes
on smear. Two subsequent taps were done to
relieve signs of tamponade and on one of these
occasions air was injected (Fig. 1). A
pen-cardial rub was heard occasionally, and the
electrocardiogram was compatible with
pen-carditis. Cultures from the penicardial fluid
remained sterile.
Upon repetition, cultures from the throat
and the subcutaneous abscess yielded M.
pyogenes var. aureus, resistant to penicillin
and oxytetracydine but sensitive to 10
erythromycin and chioramphenicol, so the
latter two antibiotics were substituted. On
ele-Fic. 1. Roentgenogram of chest of Case 13: Demonstration of typical findings in staphylococcal pen-carditis after aspiration of fluid and injection of air into pericardial cavity.
vation was noted in a roentgenogram of the
left tibia adjacent to the early area of
fluc-tuation.
During the early part of the hospital course
she was extremely ill. After about 3 weeks, she became afebrile and began to take an
interest in her surroundings. After about 8
weeks heart size and electrocardiogram had returned to normal. The osteomyelitis pro-gressed to rarefaction and sequestration of
bone. Proteus morganii was cultured for a
time from drainage from the abscess.
Strepto-mycin was used and the subcutaneous
ab-scess finally healed. There was still
roent-genographic evidence of chronic osteomyelitis
a year later.
Comment
It was felt that this child had a
staphylo-coccal bacteremia, possibly arising from an
ab-scess adjacent to the knee, complicated by bronchopneumonia, pericarditis and
osteo-myelitis. Pericarditis was not diagnosed clini-cally until signs of tamponade were obvious.
The organisms were obtained only from the
blood and the abscess. Sensitivity tests were
used in choosing antibiotics,resulting in
con-siderable changing. Penicillin resistance
be-came a problem, providing the indication for
other antibiotics. The illness was long and severe, pericarditis being the cause for
great-est concern. In retrospect, a pericardiostomy
might have hastened recovery.
ANALYSIS OF CASE RECORDS
For 1938 to 1956, there were 27 cases of
nontuberculous penicarditis in patients
un-der 20 years of age coded in our record
room. In this period the staphylococcus
was the commonest agent, accounting for
15 cases (Table I). This is in contrast to
earlier writings and may possibly be
sulfona-38 HORAN - ACUTE STAPHYLOCOCCAL PERICARDITIS
TABLE I
INCIDENCE OF NONTUBERCULOUS BACTERIAL
PER!-CARDITIS IN PATIENTS UNDER O YEARS OF AGE AT CHARITY HOSPITAL
Etiologic Agent
Number of Cases
1938-1945 1946-1955
M. pyogenes 8 7
D. pneumoniae 3
Strep. pyogenes 1
H. infiuenzae I I
Proteus rnorganii 1
Unspecified cocci 1
Undetermined pyogenic
organism 2
mides in the treatment of pneumococcal
in-fections.12 During the same period there
were only 12 cases of staphylococcal
penicar-ditis in older persons, pointing up the
previ-ously recognized higher incidence of
bacte-na! pericarditis in early life.3 An expected
finding was the greater number of males13
and of infants under 1 year.1’2
In the patients studied (Table II),
peri-carditis was part of a generalized infection.
This was manifest by recovering
staphy-lococci from the blood of 14 children from
whom cultures were obtained and by
evi-dence of involvement of multiple organs in
all cases. Pneumonia was the commonest
associated lesion, and osteomyelitis second.
By contrast, the portal of entry of the
organisms was difficult to ascertain. The
skin seemed likely in three cases, but in the
others the primary site was undetermined.
Diagnosis was difficult, and sometimes
not made during life. In Poynton’s 2
only 6% of children had a correct diagnosis
before death. In the present series the
diagnosis was made on admission in seven
cases, in the first week in three cases, after
the first week in two cases, and after death
in three cases. The symptoms are not
spe-cific in childhood, and reliance must be
placed on physical signs, which are not
uniformly present or may be misleading.14
As Koplik put it,’5 “In the cases where we
thought there was pericardial effusion,
there was none; and where we thought
there was none, there was.” Illustrative of
our diagnostic difficulties is the story of
W.A. (Case 6), a 7-year-old white male
who presented with findings so suggestive
of acute appendicitis that a laparotomy was
performed; penicarditis became apparent
on the third postoperative day. Another
puzzling presenting picture was that of
A.M. (Case 14), in whom the presence of
an urticarial rash, jaundice and marked
hepatomegaly caused confusion, although
a pericardial rub was heard on admission
and he was treated for bacteremia.
The children were sick for from 2 days
to 4 weeks before admission with symptoms
of infection. The exact onset of pericarditis
could seldom be placed. In the hospital
suspicion was aroused when bacteremia
was accompanied by cardiac enlargement
or tamponade. A friction rub was the first
sign in seven cases. Diagnosis was
con-firmed by aspiration of serous or purulent
material from the pericardial sac in eight
subjects. In two, a post-mortem penicardial
tap was done. Five cases had friction rubs,
with electrocardiographic changes or
en-larged hearts, which may have been due to
fibrinous or exudative’6 inflammation. In
all of these cases, staphylococci were
cul-tuned from blood stream, pericardial fluid,
or other sites.
The course in the hospital fell into two
general patterns. In 12 children the picture
was one of bacteremia; 7 died 1 to 21 days
after admission; 5 survived after prolonged
hospitalization. Although several of these
required pericardial taps, it was only in
those who could combat the bacteremia
that the manifestations of metastatic
in-fection, such as penicarditis or
osteomyeli-tis, were a real problem in management. In
the second type of clinical course, the
signs of penicarditis dominated the
pic-ture. W.A. (Case 6), a 7-year-old white
male, died of tamponade. A.L.B. (Case 4),
a 14-year-old white male, had two
pen-cardial taps and died after a
TABLE II
STAPHYLOCOCCAL PERICARDITIB IN CHILDREN AT CHARITY HOSPITAL
Case
? o. Age Color Sex Year
Dura-.
twa of
Symp-tom.
(Days)
. .
Admission
.
Diagnons
.
Perwar dde... Other Organ InrolremenL
Ther-apy
Oid-come
. .
Indicative
.
Sign Tap
Cu!-lure Lung Other
(I) 16 yr C. F. 1940 I4(?) Puerperal
Sepsis
Cardiomegaly + + Pneumonia Kidney S l)ied
() 4mo W. M. 1940 2 Pneumonia Pneumonia Ear
Abscesses Effusion
S Died
(3) 14 mo V. M. 194Q 4 Pericarditis
Pneumonia
Rub + + Pneumonia
Effusion
S Died
(4) 14yr \Y. M. 1943 Qi Pericarditis Cardiomegaly + + Abscesses SO I)ied
(5) Q yr W. M. 1943 28 Pericarditis Pneumonia
Cardiomegaly + + Pneumonia Effusion
PS Recovered
(6) 7 yr C. M. 1943 5 Appendicitis Rub Pneumonia Kidney S Died
(7) 12 yr W. M. 1944 7 Osteomye)iUs Tamponade + + Bone SPO Died
(8) 6yr C. F. 1944 7 Pericarditis
Osteomyelitis
Rub Pneumonia Bone
Skin
PS Recovered
(9) 8 mo C. M. 1946 14 Pneumonia Cardiomegaly + - Pneumonia Ear Effusion
P Died
(10) 8mo C. M. 1947 SO(?) Heart failure CNS disease
Skin CNS
SP Died
(II) 4 yr C. M. 1948 5 Pericarditis Pneumonia Osteomyelitis
Rub Pneumonia Bone
Empyema Joint
SP Recovered
(1Q) 4 mo C. F. 1950 15 Pneumonia Pneumonia
Myo-cardium
PB Died
(IS) 13 mo C. F. 1954 4 Pneumonia Tamponade + - Pneumonia Skin
Myo-cardium
PB Recovered
(14) O mo W. M. 1955 6 Hepatitis Bacteremia
Pericardit.is
Rub + + Pneumonia Liver PB Recovered
(iS) 16 mo C. F. 1956 4 Septicemia
Pericarditis
Rub 0 Abscesses Liver
Abscesses
PB Died
a -Sulfonamide P= Penicillin
0= Penicardiostomy B= Broad spectrum antibiotic
12-year-old white male, had two penicardi- penicillin or broad spectrum antibiotics.
ostomies and died after a 7-month illness. An attempt was made to evaluate other
The over-all mortality rate was extremely factors in prognosis for the last mentioned
high, but comparable to other reports. All group. Though the numbers are small, it
patients who were treated earlier with appeared that death was more likely to
suIfonamides,’ staphylococcal antitoxin, occur in younger infants and in those who
and/or penicardiostomy died. The only sun- had been sick for more than a week before
40 HORAN - ACUTE STAPHYLOCOCCAL PERICARDITIS
organs occurred in both groups. Finding of
organisms in cultures of blood or
pen-cardial fluid did not appear to influence
outcome, nor did the type of pericardial
in-volvement. The cause of death was almost
always overwhelming infection, rather than
the mechanical effects of the pericarditis.
This is illustrated by the following case:
A.S. (Case 15), a Negro female 16 months
of age, had coryza for several days, fever for
4 days and abdominal pain and vomiting for
2 days. The day before admission she was given an injection of penicillin for
“tonsil-litis.” On admission she was unresponsive with
blood pressure unobtainable. She was pale,
slightly cyanotic, had sunken eyes and
grunt-ing respirations, 48/mm. Although her
tern-perature was 40#{176}C,the extremities were cold
and mottled. A pericardial friction rub was
heard; heart sounds were distant, 160/mm.
The abdomen was distended and somewhat
rigid; the liver was 4 cm below the right
costal margin. Hemoglobin 10 gm/100 ml,
hematocrit 35, leukocytes 9,800/mm3,
poly-morphonuclear cells 58%, band forms 4%,
monocytes 2%, lymphocytes 36%, blood urea
nitrogen 23 mg/100 ml, total bilirubin 2.34
mg, direct 1.4 rng/100 ml. Urinalysis:
albu-mm and sugar 0, bile + , sediment contained
rare erythrocyte and leukocyte.
Electrocardio-gram was compatible with pericarditis.
Ab-dominal paracentesis produced a few drops of
serous fluid loaded with gram-positive cocci
and mononuclear cells. The admission
diag-nosis was bactenemia with penicarditis and
peritonitis, probably of staphylococcal
eti-ology. She was treated with intravenous fluids,
blood transfusions, penicillin,
chlonampheni-col and streptomycin. She was also given hydrocortisone for 2 days because of signs
of vascular collapse. The day after admission
she was jaundiced and the liver seemed
larger. Faint pink macules apparent over the
entire body the day of admission became
embolic subcutaneous nodules. Admission
blood cultures showed M. pyogenes van.
aureus. On the second day erythromycin and
tetracycline were substituted for
chlonam-phenicol on the basis of antibiotic
sensi-tivity tests. Although there was some
improve-ment by the fourth hospital day, the child
died on the eighth day. Necropsy showed
fibrinous pericarditis, multiple abscesses in
liver and lungs, and no evidence of
pen-tonitis.
In this case, in contrast to the one
previ-ously detailed, the diagnosis was made on
admission, tamponade was not a problem and the clinical course and necropsy findings
were a reflection of the generalized infection.
We were interested in the possible role
of resistance to antibiotics in affecting
prog-nosis. Sensitivity to penicillin was tested in
only five cases : one child from whom a
sensitive organism was cultured lived; in
four, the organism cultured was moderately
or completely resistant to penicillin, one
of whom received only penicillin and
sul-fonamides and died, the other three also
rceived broad spectrum antibiotics and two
lived. Recent writings emphasize the
im-portance of obtaining sensitivity tests and
of using appropriate antibiotics in adequate
dosage.18b0 It is our opinion that, when a
staphylococcal etiology is suspected, a
broad spectrum antibiotic such as
chloram-phenicol should be used along with
peni-cillin while awaiting reports as to the
or-ganism and its sensitivity.
Whether the penicardium is sufficiently
permeable to antibiotics to allow adequate
levels to be achieved within the pericardial
sac has not been investigated. Stewart and
coworkers21 found no passage of organic
dyes into the penicardial sac from the blood
stream in a 14-year-old girl with chronic
pericarditis. On the other hand, Wolfe
et al.!2 have demonstrated fair diffusion of
chlontetracydine into penicardial fluid. It
is possible that the clinical response of some
patients might be hastened by introduction
of the therapeutic agent into the sac.
The
low incidence
of penicardiostomy inthis series is an indication of the concern
with the extensive systemic infection by
those caring for the majority of the
pa-tients. The role of penicardiostomy in
pres-ent day therapy will have to be
re-evalu-ated. McGuire et al.23 are of the opinion
even now that purulent fluid always
necessi-tates surgical drainage. McKusick and
Harvey14 suggest liberal indications for the
for patients who were not responding to
medical management. We believe the
pro-cedure should be reserved for those
chil-dren who, in spite of adequate appropriate
antibiotics, show recurrent tamponade,
de-velop organisms resistant to antibiotics, or
progression of penicardial infection with
threat of death.
A final problem is the possible
subse-quent development of constrictive
pericar-ditis. The pathogenesis of this entity is still
in dispute. Aside from those due to
tuber-culosis,24 most cases are without known
etiology.252T Several authors list preceding
pericarditis as a 234 and this
may be true,35 but the evidence is often
inadequately documented and
retrospec-live. In some instances, poorly resolved
subacute infections have been interpreted
as chronic constniction.3#{176}3#{176} Shipley4#{176} states
that after pericardiostomy constrictive
pen-carditis is unusual. Deterling and
Hum-phreys’ found that acute pyogenic
peri-carditis rarely develops into chronic
con-stnictive pericarditis, and that fully
de-veloped examples of the latter may not
be traced back to preceding acute
infec-tion. There is not a sufficient number of
pa-tients so far treated by antibiotics alone to
determine whether or not such therapy
in-creases the likelihood of future
constric-tion. The follow-up of the five surviving
pa-tients of this report was brief (1 to 10
years). However, in none was evidence of
constrictive penicarditis present when the
child was last seen. There was only one
case in the hospital records which
prob-ably could be attributed to preceding acute
purulent pericarditis; this was an adult
who had inadequate antibiotic therapy
during the acute stage 2 years earlier.
SUMMARY
A survey of bacterial penicarditis in
chil-dren at Charity Hospital shows an
increas-ing preponderance of staphylococcal
infec-tions. It is impressively less common as a
complication of pneumonia and
osteomye-litis than it was two decades ago. The site
of entry for organisms is usually difficult to
determine, but the pericarditis is always
part of a generalized infection. In a
minor-ity of the patients it is the outstanding
therapeutic problem. Though the child
may be critically ill with a poor prognosis,
the outlook is better than it was in
pre-antibiotic days. Treatment should be
in-fluenced by careful evaluation of sensitivity
of the causative organism to various
anti-biotics; open pericardial drainage may be
necessary if the clinical response is poor.
Earlier diagnosis may improve the outlook,
and this will depend on a high degree of
suspicion. Other factors seem less
impor-tant in prognosis. Constrictive pericarditis
will probably not be a problem if recovery
from the acute stage occurs.
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W. and Sandusky, W. R.:Penicardiostomy for suppurative
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1 1. Pyrah, L. N. and Pain, A. B. : Acute
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17. Tonrey, R. G., Julianelle, L.A., and
Mc-Namee, H. C. : Sulfonamide therapy of
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SUMMARIO IN INTERLINGUA
Acute
Pericarditis
Staphylococcal
Depost que le efficace tractamento de
ERRATUM
penicarditis pneumococcal minus commun, Ic
staphylococcus Micrococcus pyogenes ha dis-veloppate un role progressivemente plus
promi-nente in le causation de penicarditis.
Es presentate un revista de 15 casos de
pericarditis staphylococcal in juveniles, vidite
al Hospital Caritative in le curso del passate
18 annos. Pericarditis staphylococcal es plus
commun in juveniles que in adultos,
special-mente in infantes de minus que 1 anno de etate
e in masculos. Le orificio de entrata del
or-ganismo es usualmente non demonstrabile. Le
patientes ha bacteremia con implication de
multiple organos. Pneumonia e osteomyelitis es
Ic plus commun infectiones associate. Le
diag-nose es difficile sed pete esser establite super le
base de candiomegalia, nuito de friction
pen-cardial, altenationes electrocardiographic, e
sig-nos de tamponamento. Le inflammation pote
esser fibrinose o seropurulente. In le presente
senie, Ic diagnose esseva suspicite al tempone
del admission in circa un medietate del casos.
In octo casos, pericandiocentese apportava le
confirmation.
In 12 del cases, le curse del morbo esseva
un curso de bacteremia. Penicarditis esseva un
problema therapeutic solmente in le patientes
qui poteva superar le infection generalisate. In
tres altere juveniles le signos de pericarditis
dominava le tableau clinic ab le initio.
Superviventia occurreva solmente quando
penicillina e/o antibioticos a large spectros
es-seva usate. Mesmo in iste gruppo le mortalitate
amontava a 50%. Le prognose esseva melior in
casos diagnosticate minus que un septimana
post le declaration del symptomas e in infantes
de minus que 1 anne de etate. Un therapia
basate super le sensibilitate del organismos
pathogenic a antibioticos meiora le prospecto
e es grandemente necommendate. Al tempore
pnesente, on pete expectar que Ic agente
etio-logic se revela come staphylococco con
resis-tentia a penicillina. Penicandiostomia esseva
usate rarmente in le presente serie. Le ration
esseva Ic prevalentia de extense infectiones
sys-temic. Illo es indicate in Ic caso de infantes in
qui-in despecto del use adequate de
antibio-ticos appropriate-il ha recurrentia de
tampona-mento, un disveloppamento de resistentia al
an-tibioticos in Ic collection pericardial, 0
pro-gression del infection penicardial con peniculo
de monte.
In the article A CONTROLLED STUDY OF THE USE OF PROPHYLACFIC
ANTIMIcROBIALS IN PREMATURE INFA1’i-rs by Giuliana Gialdroni-Grassi,
Charles V. Pryles, and Maxwell Finland (PimlAmics, 18:899, 1956), the
section starting in the middle of the first column on page 900 should have
read:
ADMINISTRATION OF ANTIMIGROBLAL AGENTS. All infants born in this
hospital weighing 2.27 kg or less and admitted to the nursery for
prema-tune infants from April through September, 1955, were included in the
