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Nigerian J Paediatrics 2017 vol 44 issue 1

Nigerian J Paediatrics 2017 vol 44 issue 1

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Staphylococcal septicaemia complicated with purulent pericarditis in an infant A case report
Niger J Paediatr 2017; 44 (2):81 83
CASE REPORT
Oloyede IP
Staphylococcal septicaemia
Essien PU
complicated with purulent
pericarditis in an infant: A case
report
DOI:http://dx.doi.org/10.4314/njp.v44i2.7
Accepted: 18th August 2016
Abstract : Purulent pericarditis is
fant is here presented to illustrate
a rare complication of sepsis. It is
the importance of a high index of
Oloyede IP (
)
almost exclusively a complication
suspicion and simple investiga-
Essien PU
from an underlying condition
tions in its diagnosis in resource
Department of Paediatrics,
rather than a primary infection.
limited practice. In addition, the
University of Uyo Teaching
Staphylococcus aureus is the
importance of prompt treatment
Hospital, P.M.B 1136, Uyo Akwa
commonest aetiologic agent. Its
with drainage of the abscess and
Ibom State, Nigeria.
diagnosis requires a high index of
use of appropriate antibiotics to
Email: isooloyede@yahoo.com
suspicion especially in the pres-
achieve a good prognosis is
ence of persistent fever and signs
shown.
of cardiac tamponade in spite of
appropriate antibiotic use. A case
Key words: Staphylococcus,
of purulent pericarditis in an in-
Purulent pericarditis
Introduction
min C and Ampiclox syrup. Other associated symptoms
were high grade continuous fever; frequent loose stools;
Pericardial abscess has been a rare complication of sep-
pallor of the hands and feet and progressively worsening
sis in both adults and children.
1,2
The diagnosis is usu-
fast breathing in the absence of cyainosis. A day before
ally suspected when fever persist with the development
presentation in the paediatric emergency unit she devel-
of cardiac tamponade. Staphylococcus aureus is the
3
oped a painful swelling of the left shoulder and upper
commonest causative factor incriminated in the patho-
left chest wall.
genesis of purulent pericarditis.
3,4
In Nigerian children
There was no history suggestive of sickle cell disease.
Staphylococcus aureus accounted for 44% of non-
She was predominantly breastfed for four months, after
tuberculous causes of infective pericarditis. Staphylo-
5
which bottle feeds were introduced. Family diet was
coccal septicemia can occur in the absence of any identi-
introduced at age eight months and feeding frequency
fied portal of entry or presence of an infective focus.
6
was 3-4 times. Immunizations were adequate for age and
There is evidence that purulent pericarditis has been
developmental milestones were appropriate.
under diagnosed in the pediatric age group, secondary to
She was the second in a monogamous family of two
non-specific presentations in childhood and limited car-
children. Her family lived in a three room apartment,
diac diagnostic equipment in developing countries like
drank borehole water, and used water-closet toi-
Nigeria.
2,4,5
There is a paucity of recent studies of puru-
let.Mother was 30 years old and father 32 years old.
lent pericarditis in infants.
Both parents had secondary level of education.
This study presents a one year old girl who was initially
managed as a case of severe staphylococcal septicemia
Examination findings revealed an acutely ill child, feb-
with congestive cardiac failure and severe anaemia.
rile, severely pale (PCV 12%), but acyanosed and anic-
However, with worsening respiratory signs, further in-
teric. Her weight was 8kg (80% of expected), occipito-
vestigation revealed purulent pericarditis for which she
frontal circumference 45cm, and length of 77cm. The
was managed with appreciative response.
left shoulder and left sternoclavicular region were swol-
len, tender, firm and with differential warmth. There was
Case Presentation
a diffuse left leg swelling with a circumference of 19cm
compared with the right leg that was 15cm (measured
U.P. was a one year old girl from a semi-urban area in
10cm from the left patella). The left leg was shiny, ten-
southern Nigeria, who presented with a five days history
der, and soft, with differential warmth with three inci-
of limping and painful swelling of the left ankle. She
sion wounds discharging purulent fluid from its anterior
was taken to a traditional bone setter who massaged the
surface.
ankle for three days. With worsening of symptoms and
The chest wall was asymmetrical with swelling of the
progressive interference with walking, she was taken to
left hemi thorax. She was dyspnoeic and tachypnoeic,
a patent medicine dealer. At the patent medicine store
with increased cardiac dullness and crepitation. She had
the swelling was incised and about 50mls of sanguino-
a pulse rate of 148 beats per minute; apex beat was at
the 4 left intercostal space, mid-clavicular line; and the
th
purulent fluid was drained and she was treated with vita-
82
first and second heart sounds only were heard and nor-
She was discharged home after 38days stay in the hospi-
mal. The liver was palpably enlarged by 12cm, firm and
tal, with normal vital signs and chest examination find-
tender.
ings. In addition, the left shoulder and leg swellings had
The initial diagnoses were bronchopneumonia with con-
resolved. (Fig 3) Investigation results showed normal
gestive cardiac failure, pyomyositis of the left leg, and
FBC with PCV of 34% and normal cardiac silhouette on
Septic arthritis of the left sternoclavicular and shoulder
post-pericardiostomy chest X-ray.
joint. She was transfused with 120mls of settled cells
and intravenous gentamycin and ceftriaxone were com-
Fig 3: Post-operative picture of Child with Purulent pericardi-
menced.
tis showing swollen left leg, arm and Pericardiocentasis scar
The following investigation results were obtained: left
leg X-ray showed increased soft tissue swelling with no
bony involvement. Diagnostic needle aspirations of the
left shoulder joint and left leg yielded 400mls and 12mls
of purulent aspirate respectively. Culture results of the
aspirates yielded Staphylococcus aureus sensitive to gen-
tamycin, cloxacillin and ciprofloxacin. Blood culture
yielded no growth. However, full blood count showed
polymorphonuclear leukocytosis (Total WBC:23.4x10 /
9
l; neutrophils: 65%) with neutrophilic left shift and toxic
granulations. Haemoglobin genotype was AA and HIV
serology was negative. Chest X-ray showed globular
heart with cardiothoracic ratio of 71%. (Fig 1)
Fig 1
Discussion
Bacterial pericarditis often is not readily apparent as it is
almost exclusively a complication from an underlying
condition rather than a primary infection as seen in the
index case. The underlying condition in our index case
2
was pneumonia, pyomyositis and arthritis, which is
similar to earlier reports in which pneumonia and osteo-
myelitis were the major underlying conditions.
3,4
In ad-
dition, the presence of hepatomegaly in our case cor-
roborated a previous report where it was an important
diagnostic sign. However, the etiology of hepatomegaly
3
Treatment included; Elevation of the left lower limb
with application of above-knee Plaster Of Paris back-
is likely multifactorial with cardiac failure and septicae-
slab. In addition, antibiotics were changed to intrave-
mia playing a role. The negative blood culture result in
nous ampicillin-cloxacillin, for six weeks, and subse-
spite of a positive joint aspirate culture was probably
quently replaced with ciprofloxacin.
due to the pharmacokinetics of antibiotics with a more
prolonged course of antibiotic administration needed to
On the 17 day of admission, she became restless, with
th
allow for bone and joint penetration. Hence the blood
worsening respiratory distress and cyanosis. Oxygen
culture was negative due to early onset of action of anti-
therapy was commenced and urgent echocardiography
biotics, while the joint aspirates which needed a more
revealed massive concentric pericardial effusion measur-
prolonged course of antibiotics came back positive.
ing 28mm, with normal ventricular function. (Fig 2)
However, the pericardial aspirates were negative, proba-
Bedside subxiphoid pericardiocentesis performed for
bly as a result of prolonged antibiotic use before the
relief yielded 300mls of purulent aspirate.Culture of the
aspirate was cultured. These findings were similar to
pericardial aspirate was negative. Under- water seal
that obtained in a study among Omani infants in which
transthoracic tube pericardiostomy was inserted on the
not all of their pericardial aspirate culture yielded iso-
lates. The Children with negative cultures had received
7
19 day of admission with drainage over 11 days.
th
antibiotics prior to the collection of samples. In contrast,
Fig 2
a study of Zimbabwean children had a 72% yield of bac-
teria from the pericardial aspirate.
3
Furthermore, the worsening respiratory distress and ap-
pearance of cyanosis in the index case seemed to be a
pointer to the development of cardiac tamponade which
is the most frequent complication of purulent pericardi-
tis.
3,7,8
However the absence of engorged neck veins and
impalpable peripheral pulses expected in cardiac tampo-
nade was not surprising as an earlier report showed a
prevalence of 34%.
5
83
In addition, her chest X-ray revealed a globular heart.
Conclusion
However, the presence of a globular heart on chest X-
ray reflects an effusion of at least 250mls volume, which
In resource limited settings with limited diagnostic car-
maybe present without pathologic effects and thus a
diac gadgets, a high index of suspicion, diligent physical
globular heart is not diagnostic of a tamponade effect.
examination and simple investigations are essential for
Therefore, an echocardiography is an invaluable nonin-
the diagnosis of purulent pericarditis in children. The
vasive means to evaluate a patient when tamponade is
use of appropriate antibiotics and pericardiostomy gives
suspected. The use of appropriate antibiotics combined
8
a good outcome in children with purulent pericarditis.
with transthoracic pericardiostomy resulted in a com-
plete resolution of symptoms.
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