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A previously healthy year-old man was admitted with asthenia, fever, shivering, oppressive chest pain, and orthopnea of three-day duration. He had an infected finger wound and lymphangitis on his forearm, self-medicated with topical ointments unsuccessfully. He was febrile 39 oC , hypotensive, with low SpO2 and oliguria, without peripheral edema, hepatojugular reflux or pericardial friction rub. He suddenly had jugular distention, muffled heart sounds and paradoxical pulse, indicating cardiac tamponade, further confirmed.
Erythrocyte sedimentation rate, neutrophil-lymphocyte count ratio, C-reactive protein, and procalcitonin were elevated. Despite of intensive care he had irreversible cardiac arrest. Autopsy revealed hemopericardium causing death by cardiac tamponade and pulmonary edema, in addition to fibrinous pericarditis, hepatic abscess, and acute tubular necrosis. Eventual tuberculosis coinfection and pericardial involvement by malignancy were ruled out.
The role of autopsy to better understand mechanisms of cardiac tamponade is commented. The pericardial sac of normal people contains between 15 to 50 mL of serous fluid. Hemopericardium may be idiopathic, or due to pacemaker or catheter insertion, pericardiotomy, aortic dissection, malignancy, trauma, uremia, tuberculosis and drugs. The modality of drainage procedure is not yet consensual and depends upon the type of effusion, general patient health, physician experience, and institutional resources.
An year-old male searched for medical attention complaining of asthenia, fever, shivering, oppressive thoracic pain and orthopnea that started three days prior to admission. His medical antecedents were unremarkable, without alcohol abuse or use of any illicit drugs. He had been fishing in a lagoon and suffered a contaminated injury in the right index finger that evolved with local inflammatory signs and lymphangitis over the ipsilateral forearm. Instead of proper medical orientation he decided control the wound utilizing topical treatment.
Physical examination on admission showed 39 o C, hypotension, tachycardia, low SpO 2 , and oliguria; so, underwent immediate broad spectrum antimicrobials and intensive care support. There was no peripheral edema, hepatojugular reflux or pericardial friction rub; the chest pain intensity did not change with chest positions, and the breath sounds were decreased.
He evolved hypotense, with jugular distention, muffled heart sounds and paradoxical pulse. Routine laboratory tests revealed anemia, neutrophilic leukocytosis, thrombocytopenia, hypoalbuminemia, hyponatremia, hyperglycemia; elevated levels of transaminases, urea and creatinine; and urinalysis showed hematuria, high sodium concentration and granular casts.
The determinations of erythrocyte sedimentation rate, neutrophil-lymphocyte count ratio, C-reactive protein, and procalcitonin revealed significant elevated levels; whereas the pro-BNP, and all the markers of myocardial necrosis were detected within the normal ranges.
The electrocardiographic low voltage and PR segment depression suggesting pericardial effusion, and the echocardiogram showing huge pericardial effusion, collapse of the right chambers, and abnormal movement of interventricular septum indicated cardiac tamponade. A sudden cardiopulmonary arrest occurred before the hospital care for more than four hours and, in spite of the routine resuscitation maneuvers, the death of the patient was inevitable.
On postmortem study, the pericardial section revealed a massive hemopericardium, which caused the cardiac tamponade.
The heart weighed g 0. The aorta and coronary arteries as well as cardiac cavities and valves were all intact. There was associated fibrinous pericarditis, pulmonary edema, hepatic abscess, and acute tubular necrosis Figure 1.
Pulmonary and renal abscesses were also found. Methicillin-resistant Staphylococcus aureus MRSA was isolated in abscesses, blood, and pericardial fluid. Cardiac tamponade due to purulent pericarditis may be fatal without pericardiocentesis; the echocardiography confirming this diagnosis can be life-saving in emergency attention. The infection herein described was acquired in the community, and the agent invaded the blood stream through a skin wound.
Based on the autopsy findings, the diagnoses of pericarditis, hemopericardium, and hepatic, renal and pulmonary abscesses, in addition to acute tubular necrosis were characterized.
Immediately before death, clinical and complementary data were strongly consistent with the diagnosis of pericarditis and voluminous pericardial effusion evolving to cardiac tamponade. The patient herein reported had an overlap of fibrinous pericarditis with hemopericardium; 6 , 17 the fluid was hemorrhagic, but histologic features were consistent with fibrinous pericarditis. The hypothesis of a S.
Autopsies can play a significant role to better understanding the physiopathological mechanisms involved in acute pericarditis with effusion causing death by cardiac tamponade. Hemopericardium may be associated with benign and malignant causes of acute pericarditis. Testing biomarkers of bloodstream infection may have clinical value in these conditions.
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Cardiac tamponade with community-acquired methicillin-resistant Staphylococcus aureus pericarditis. Intern Med ;52 15 Pleural and pericardial empyema in a patient with continuous ambulatory peritoneal dialysis peritonitis.
Korean J Intern Med ;28 5 Purulent pericarditis secondary to community-acquired, methicillin-resistant Staphylococcus aureus in previously healthy children. A sign of the times? Ann Am Thorac Soc ;10 3 Pyopericardium with cardiac tamponade in a Nigerian child with acute osteomyelitis. J Cardiovasc Echogr ;27 2 Metastatic complications of pericarditis and cardiac tamponade as a result of Staphylococcus aureus bacteremia developing during antimicrobial therapy.
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I Diretriz Brasileira de Miocardites e Pericardites. Arq Bras Cardiol ; 4 suppl. Large hemorrhagic pericardial effusion. Isr Med Assoc J ;14 6 Willner D, Bhimji S. Pericardial effusion. Sudden cardiac arrest caused by tuberculous pericarditis with hemorrhagic pericardial effusion. Intern Med ;51 22 Disclosure of potential conflicts of interest: The author had full freedom of manuscript preparation and there were no potential conflicts of interest.
Armed Forces Hospital. Telephone: Fax: E-mail: vitorinomodesto gmail. This is an open-access article distributed under the terms of the Creative Commons Attribution License. Servicios Personalizados Revista. Similares en SciELO. Clinical cases Hemopericardium, cardiac tamponade, and liver abscess in a young male. Abstract: A previously healthy year-old man was admitted with asthenia, fever, shivering, oppressive chest pain, and orthopnea of three-day duration.
Case presentation An year-old male searched for medical attention complaining of asthenia, fever, shivering, oppressive thoracic pain and orthopnea that started three days prior to admission.
Conclusions Autopsies can play a significant role to better understanding the physiopathological mechanisms involved in acute pericarditis with effusion causing death by cardiac tamponade. References 1. Received: July 24, ; Accepted: October 05, Montecito No.
Examen de frote periferico: "linfocitosis reactiva de etiologia a determinar" que signica esto?