From the Departments of Pathology and *Neonatology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai 400 012, India.
Reprint requests: Dr. Pradeep Vaideeswar, Associate Professor, Department of Pathology, Seth G.S. Medical College, and K.E.M. Hospital, Parel, Mumbai 400 012, India.
Manuscript Received: February 19, 1998; Initial review completed: March 31, 1998;
Revision Accepted: June 26, 1998
Neonatal purulent pericarditis is a rare condition usually seen as a complication of sepsis. We report a case in a 29 day old neonate.
A 29-day-old male child had recurrent
episodes of breathlessness from the twelfth day of life, requiring hospitalization and treatment with intravenous antibiotics. Details of birth history and subsequent hospitalization were not available. On present
examination, the condition was poor with a heart rate of 124/minute and respiratory rate of 64/minute. There was respiratory distress, central cyanosis and decreased activity. On auscultation, the heart sounds were soft with bilateral crepitations.
A clinical diagnosis of congenital heart disease with bronchopneumonia was entertained. Hematological profile revealed mild neutrophilic leukocytosis and anemia. Chest X-ray showed an 'egg on end' appearance suggestive of transposition of great arteries. Electrocardiogram was not done. Blood was not collected for culture studies. Blood gas analysis was suggestive of respiratory alkalosis. The child was put on ventilatory support in view of severe cyanosis and florid bilateral crepitations. He was treated with antibiotics and bronchodilators, but died within eight hours of admission.
A complete autopsy was performed. The heart was moderately enlarged and weighed
25 g. There was marked thickening of the parietal and visceral layers of the pericardium with dense adhesions between them. The layers enclosed a large pocket on the right border of the heart (Fig. 1). It lay over part of the anterior and posterior surfaces of the right atrium and ventricle and contained yellow granular material. There was significant obliteration of the right sided cardiac chambers. Section from this area revealed marked thickened, fibrotic and vascularized pericardia enclosing purulent exudate that was partly organised. Special stains revealed few Gram positive cocci. No fungal elements were identified. Right coronary artery was normal. Lungs appeared normal on gross examination, but microscopically showed clusters of haemosiderophages
in few groups of alveoli. There was no septic focus in the lung or any other organ. The cause of death was attributed to chronic suppurative pericarditis and cardiac tamponade.
Fig. 1. Pus containing
at the right border of heart. Note small size of the right ventricular
(RV) cavity. P - pericardium, v - visceral, p -parietal; LA - left atrium, MV - mitral valve, LV - left ventricle, A - Aorta.
Suppurative pericarditis rarely occurs in the neonatal age group. It most commonly
presents as a phenomenon secondary to infection, especially involving the lung, and is seldom
primary(1). Bacteria are the commonest organisms implicated aha. nearly 20 cases of proven bacterial
etiology have been reported in the past 50
years(2). The other organisms include Candida species and Mycoplasma hominis.
The reported case did not reveal any septic focus elsewhere in the body. It is
quite possible that prior antibiotic therapy may have led to resolution of purulent inflammatory focus, leaving behind a smouldering infection in the pericardium. Culture studies were not done, but special stains revealed many Gram positive cocci.
The neonate usually manifests with
symptomatology of sepsis with respiratory disease. The clinical features of pericarditis are subtle(3). Apart from features of cardio-respiratory embarassment,
the neonate in the present case did not have any clinical evidence of sepsis.
However, it must be remembered that cardiac failure in a neonate with a septic
infection must alert the treating physician to the presence of purulent pericarditis.
Neonatal suppurative pericarditis is a life threatening condition that requires prompt diagnosis and treatment. Confirmation always requires either a two dimensional echocardiography or computed tomography(4,5). Mere antibiotic coverage is not sufficient for resolution of the infection. It often leads to loculation of the exudate and development of constrictive pericarditis(6), as was well seen in our case. Antibiotic therapy should always be coupled by simple pericardiocentesis or surgical pericardiostomy or pericardiectomy(3).
The authors thank the Dean, Seth G.S.
Medical College and K.E.M. Hospital, Mumbai for granting permission to publish this article.
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