Nigerian Journal of Paediatrics

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

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-

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.

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

purulent fluid was drained and she was treated with vita-

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 /

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

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

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

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

19 day of admission with drainage over 11 days.

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.

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%.

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

a good outcome in children with purulent pericarditis.

with transthoracic pericardiostomy resulted in a com-

plete resolution of symptoms.

References

1. Capov I, Weschler J, Sumbera

4. Adebo AO, Osinowo O,

7. Ballal N, Vyas H, Novelli V.

J, Pavlik M, Jedlicka V. Peri-

Adebonojo SA, Grillo IA. Pu-

Acute Pericarditis in Omani

cardial abscess - a very rare

rulent Pericarditis: A Continu-

children. J Trop Pediatr 1991;

complication. Acta Chir Hung

ing Surgical Challenge. J Natl

37(5): 232-4.

1999; 38(1): 19-21.

Med Assoc 1981; 73(5): 439 –

8. Shiber JR. Purulent Pericardi-

2. Musa AA, Salami BA, Tade

443.

tis: Acute Infections and

OA. Purulent Pericarditis Com-

Jaiyesimi F, Abioye AA, Antia

Chronic Complications. Hos-

plicating Septicaemia: Report

AU. Infective pericarditis in

pital Physician 2008; 45: 9-

of Two Cases. East Afr Med J

Nigerian children. Arch Dis

17.

2003; 80(6): 331-3.

Child 1979; 54: 384-90.

Sinzobahamvya N, Ikeogu MO.

del Rio A, Cervera C, Moreno

Purulent pericarditis. Arch Dis

A, Moreillon P, Miro JM. Pa-

Child 1987; 62: 696-699

tients at Risk of Staphylococ-

cus aureus Bloodstream Infec-

tion. CID 2008; 48(Suppl 4);

S246-53.