AN UNUSUAL COMPLICATION OF PNEUMONIA

by Karthikeyan.S Prof P.Vijayaraghavan’s Unit

5/6/10 Mr.Kanagaraj , 23/M, came to the opd with

c/o -

fever - 7 days

cough with expectoration - 5 days

breathlessness - 3 days

HOPI-

• fever – high grade,continuous , associated with chills and rigors • cough with expectoration - sputum, moderate amount yellow coloured not blood stained not foul smelling

•Breathlessness – at rest,grade 4,agg.by exertion, not relieved by rest, no PND/Orthopnea

•chest pain – left sided,lower chest wall, pricking type,agg. by inspiration

•No c/o palpitations,syncope

•No c/o urine output,abdominal distension/pain leg swelling

• No c/o jaundice

•No c/o head ache,blurring of vision, altered sensorium,involuntary movements

•No c/o vomitting,diarrhea

•No c/o joint swelling,rashes

•No c/o loss of weight/but loss of appetite+

•Past History –

No c/o similar illness in the past No h/o HT, DM,TB,ASTHMA,RHD

•Personal History- Not a smoker,alcoholic Mixed diet No h/o exposure to CSW

•Contact History-

No history of contact with TB

General examination-

Conscious, oriented, No pallor/icterus No cyanosis/clubbing No generalised lymphadenopathy moderately dehydration+ Dyspneic Febrile, Temp-101 F JVP elevated

Vitals- Pulse- 120/min, regular, nomal volume

B.P- 100/70 mm Hg

System examination:

CVS – S1S2 normally heard,

no murmur

RS – BAE,

Over left mammary,axillary,infra-axillary, lower interscapular and infra-scapular areas- Crepitations+

VF/VR

Bronchial breathing-tubular

Egophony+

ABDOMEN: soft, no organomegaly

CNS: No focal neurological deficit

Provisional Diagnosis

Left lower lobe Pneumonitis with ?Myocarditis

ECG:

ECG:

Provisional diagnosis

PERICARDIAL EFFUSION WITH ?MILD/LOW PRESSURE CARDIAC

TAMPONADE

ECHO:Dense echogenic shadow in pericardial cavity

Normal chambers and valves

? Effusive pericarditis with pyopericardium

SUGGESTED: Emergency pericardial window

Baseline Investigations:CBC: RFT: Hb: 12 g B.UREA:20

mg/dl TC: 13,500 Sr.Creatinine:1

mg/dl DC: P75 L24E1 Sr.Electrolytes

ESR: 20/40mm Na - 138 Plt: 1.2 lakhs K - 4.1 PCV:36% Urine analysis: albumin –nil sugar-nil

deposits- 1-2 pus cells

Contd…CPK-MB-no kit

Sputum C/S

Sputum AFB (sample sent)

Blood C/S

ELISA –HIVManteaux- negative

Initial treatment:

Inj.Ceftriaxone 1g i.v b.dInj.Metronidazole 500 mg i.v t.i.d

Inj.Deriphylline 2cc i.v b.dInj.Ranitidine 50 mg i.v b.d

T.Bromhexine 1 t.i.dT.Paracetomol 1 t.i.d

Salbutamol nebulisation 6 hrlyTepid sponging

6/6/10

Anaesthetic fitness obtained for emergency pericardectomy

Pt. transferred to CTS ward

16/6/10 Pt. GC was stable, afebrile, not dyspneic

JVP - prominent “y” descent

Vitals : stable

CVS,ABDOMEN,CNS – NAD

RS: BAE, minimal crepitations+ in left lower lung

fields

Contd….Sputum C/S – Streptococcus pneumoniae

grown, sensitive to cefotaxim,ceftriaxone

Sputum AFB –negative

Blood C/S – no growth

ELISA-HIV- negative

17/6/10 Repeat Echo: Pericardial effusion 14 mm +

Moderately dense strands + in posterior aspect

Septal bounce+

IVC dilated

Minimal respiratory variation Features S/O constrictive pericarditis

Final diagnosis LEFT LOWER LOBE PNEUMONITIS

EFFUSIVE PERICARDITIS

CONSTRICTIVE PERICARDITIS

5/7/10

Pericardectomy was done(! finally)

Specimen AFB-negative

c/s – No growth

Biopsy-report not obtained

Post op ECG:

Discussion : PERICARDITIS - inflammation of the pericardium ,both

visceral and parietal

CLASSIFICATION : 1.Clinical 2.Aetiological

Clinical classification 1.acute pericarditis < 6 weeks a. fibrinous b.effusive 2.subacute pericarditis 6 weeks – 6 months a.effusive b.constrictive3.chronic pericarditis > 6 months a. constrictive b. effusive

Aetiological classification 1. Infectious pericarditis

a.viral – cox A, B ,ECHO ,mumps ,HIV, hepatitis b.pyogenic- pneumococcus ,staphylococcus ,neisseria legionella c.tuberculosis d.fungal e.protozoal 2.Non infectious: a. AMI d. myxedema g. trauma b. uremia e. cholesterol h.aortic

dissection c.neoplasia f. chylopericardium i.post

irradiation FAMILIAL –mulibrey nanism

3. Pericarditis related to hypersensitivity /autoimmunity:

a.rheumatic fever b.collagen vascular diseases c. drugs - procainamide ,hydralazine d.post cardiac injury 1) dressler 2) post pericardiotomy 3) post traumatic

Clinical picture Chest pain –sharp ,pleuritic ,lower left sternal border, radiation to the trapezius,aggravated on lying down,relieved on upright posture ; others: fever ,dyspnea ,cough ,hiccough Signs pericardial friction rub - 85 % patients ,lower left sternal border ,grating /scratching - three components –ventricular systole ,early diastole ,atrial contraction Signs that are clues to etiological diagnosis

Laboratory investigations :

ECG – changes secondary to acute subepicardial inflammation 4 stages ;-- stage 1. widespread ST segment elevation

with upward concavity ,PR segment

depression stage 2 . ST segment returning to normal stage 3 . T wave inversion stage 4 . ECG returning to normal differential diagnosis– AMI ,ERS

CARDIAC ENZYMES – CPK MB and TROP I elevated-silent myo

carditis TROP I modestly elevated

without CPKMB –epicardial

inflammation ECHO: usually normal silent effusion ventricular dysfunction associated with myo

carditis OTHER INV; CBC ,CHEST X RAY ,INV. TO FIND OUT SPECIFIC

AETIOLOGY LIKE ANA FOR SLE

MANAGEMENT Depends on the aetiology :

If the diagnosis is uncertain it is labelled as ‘acute idiopathic

pericarditis ‘ treatment of which is T.Brufen 600 mg tid if no or inadequate response T. colchicine or T.prednisolone can be

given if still no response / develops effusion admission and diagnostic centesis and

treat accordingly

Viral pericarditis Most common infection of the pericardium ;

Coxsackie A,B , mumps ,ECHO ,influenza ,HIV, CMV ,

Develops 10 – 12 days after a presumed viral illness Presents in association with pneumonitis & pleural

effusion Management ; hyper immune globulin – CMV, parvovirus ,adeno virus interferon alpha – coxsackie B aspirin 2 – 4 mg /day brufen/colchicine / prednisolone

Bacterial pericarditis Characterised by purulent effusion Organisms – staphylococcus ,peumococcus ,streptococcus, neisseria ,legionella Mode of spread – 1. contiguous –extension from pneumonia /empyema head neck /mediastinum 2. haematogenous Clinical manifestations ;- high grade fever ,chills ,rigor chest pain , dyspnea ,pericardial rub

Laboratory features ;- CBC – leucocytosis with left shift , Pericardial fluid- high protein ,low glucose ,increased neutrophils ,high LDH specific organism can be grown

Management Suspected /proven bacterial pericarditis is a medical

emergency

Closed pericardiocentesis and subsequent catheter drainage for three to four days

Purulent pericardial effusions likely to recur ,hence pericardial window necessary

If patient develops constrictive pericarditis – pericardiectomy done

Tuberculous pericarditis More common in the developing world ;more in immuno

compromised;

Clinical picture : - chronic systemic illness with pericardial effusion /constrictive pericarditis ; -only 3 -4% present with acute/subacute pericarditis;

Pericardial involvement usually secondary to peribronchial peritracheal or mediastinal lymphnode involvement

Haematogenous spread is also common Contiguous spread from a necrotic focus less common

Diagnosis Definite diagnosis –isolating the organism from the pericardial fluid or biopsy—very

difficult

Adjuvant investigations – pericardial fluid ADA > 40 u/l

mantoux,IFN gamma

PCR to detect M.tuberculosis DNA Management ;- even if the definitive diagnosis is lacking but

biopsy shows granuloma, anti tuberculous drugs can be startedCorticosteroids -role inconclusive

Constrictive pericarditis Its an end stage of inflammatory process involving the pericardium

Causes : Idiopathic,infection ,irradiation ,postsurgical, Autoimmune ,neoplastic ,uremia ,posttrauma sarcoidosis ,methysergide therapy ,

Tuberculosis is an important cause in developing countries;

:

Pathophysiology:

inflammation of the pericardium

fibrosis & calcification adhesion between visceral & parietal

pericardium constrictive pericarditis

Hemodynamics restricted filling of heart

elevation and equilibration of filling pressures in all chambers ventricles fill abnormally & rapidly in early diastole

early to middiastole ventricular filling ceases due to stiff pericardium /all filling occurs in early diastole

“the prominent y descent”

Contd……. 1. Failure of transmission of intrathoracic pressure to cardiac

chambers –vital factor in the hemodynamics of constrictive pericarditis ; inspiration –drop in intrathoracic pressure

drop in pulmonary venous pressure but not left atrial pressure

decreased pulmonary vein to left atrial pressure gradient leading to dec.LV filling & inc.RV

filling & septal shift to left “Exaggerated respiratory variation in flow velocity”

Clinical presentation Initial symptoms : leg swelling ,abdominal distension, anasarca Later – exertional dyspnea ,cough ,orthopnea ,muscle

wasting , cachexia Signs : elevated JVP –prominent x & y descent –results in

M/W pattern Kussmaul’s sign positive Pericardial knock present TR murmur + hepatomegaly +

Laboratory investigations ECG ; nonspecific T wave changes reduced voltage of QRS complex atrial fibrillation Chest x ray; cardiac silhoutte enlarged pericardial calcification pleural effusion Prominent pulmonary vasculatureECHO ; pericardial thickening ,abrupt displacement of

the IVS during early diastole ;septal bounce SVC & IVC dilated ;Doppler flow velocity –exaggerated respiratory variations in mitral flow velocityCardiac catheterisation– square root sign

Management Medical management ; -- diuretics ,salt restriction

Surgical management ; --pericardiectomy is the definitive treatment Prognosis LV diastolic function returns to normal in 90 –

95 % of cases early or late poor prognosis associated with myocardial

atrophy or fibrosis ,incomplete resection ,mediastinal

fibrosis

Cardiac tamponade :

accumulation of fluid in pericardial space

sufficent to cause obstruction to inflow of blood

cardiac tamponade

Quantity of fluid 200 ml -if accumulates rapidly; >2000 ml –if slow accumulation;

Causes 1.Neoplastic disease

2.Idiopathic pericarditis

3.Renal failure 4. Tuberculosis

5.Hemopericardium due to use of anticoagulants

6.Bleeding into the pericardial cavity following cardiac surgeries

Hemodynamics fluid accumulation in pericardial sac

atrial & ventricular diastolic pressure rise

equalise at a pressure similar to that of pericardial sac -15 – 20 mmhg

small end diastolic ventricular volume /stroke volume

hypotension

The mean initial right atrial pressure is lower than the left

atrial pressure and hence as the fluid accumulates right

sided diastolic collapse occurs;

The total heart volume is fixed in cardiac tamponade ;

The loss of y descent and the presence of x descent can be

explained by the above concept

y descent occurs usually when tricuspid valve

opens

blood is not leaving the heart

no blood can enter the heart

loss of y descent

x descent occurs during ventricular ejection

blood leaves the heart

venous inflow present

x descent retained

Pulsus paradoxus During inspiration

increase in rt.heart filling

IVS shift to left

decreased LV filling ( due to constancy of

heart volume)

decreased LV stroke volume

Clinical features

Cough ,dyspnea ,orthopnea Pericardial pain /discomfort

Signs – diaphioretic ,cyanosis ,altered

sensorium ,hypotension tachycardia ,tachypnea pulsus paradoxus , BECK’s triad

Lab. Investigations ECG ; reduced voltage and electrical alternans

( antero posterior swinging of the heart ) Chest x ray ;- enlarged cardiac silhoutte ,flask shaped heart oligaemic lung fields Echo ; pericardial effusions , RA and RV diastolic collapse exaggerated respiratory variations in mitral flow velocities

Management It is a potential medical emergency

In critically ill patients emergency closed pericardiocentesis

is done

In mild effusions such as due to idipathic effusions conservative

management with a course of NSAIDs /colchicine used

In case of loculated effusion and effusion containing clots /purulent exudates an open approach with a window is advisable

Effusive constrictive pericarditis Combination of tense effusion and constriction of

heart by thickened pericardium Features of effusion causing compression and

constrictive pericarditis present Causes ; tuberculosis,

scleroderma ,radiation ,neoplasm ,renal failure Diagnosis pericardiocentesis and biopsy Treatment pericardiectomy

Low pressure tamponade Mild tamponade where intra pericardial pressure is

slightly elevated to 5 – 10 mmhg

CVP is slightly elevated

Arterial pressure is unaffected No paradoxical pulse ;Usually associated with

hypovolemia

Treatment ; periacrdiocentesis

References

Harrison’s principles of internal medicine -17 th edition Braunwald’s heart disease -8 th edition