The New England Journal of MedicineA Tight Squeeze

Purulent Pericarditis: A Rare but Potentially Fatal Complication of Intravenous Drug Use

A 66-year-old man with a history of intravenous drug use presented to the emergency department with progressive chest discomfort, leading to the diagnosis of purulent pericarditis caused by methicillin-resistant Staphylococcus aureus (MRSA). This case highlights the importance of prompt recognition and management of acute pericarditis, particularly in high-risk populations. The patient’s clinical course, from initial presentation through diagnosis and treatment, offers valuable insights into the management of this potentially life-threatening condition.

Key Points:

• The patient presented with a 3-day history of worsening chest pain, shortness of breath, and systemic symptoms.
• Initial examination revealed a three-component friction rub along the left sternal border and elevated jugular venous pressure.
• Laboratory results showed leukocytosis, elevated inflammatory markers, and mild troponin elevation.
• ECG demonstrated widespread upsloping ST-segment elevation and PR-segment depression, consistent with acute pericarditis.
• Echocardiography revealed a moderate pericardial effusion with signs of tamponade.
• The patient developed atrial fibrillation with rapid ventricular response and hypotension, requiring cardioversion and fluid resuscitation.
• Emergency pericardiocentesis yielded 360 cm3 of purulent fluid.
• Pericardial fluid analysis strongly suggested bacterial purulent pericarditis, later confirmed as MRSA.
• Initial empirical antimicrobial therapy with cefepime and vancomycin was changed to vancomycin monotherapy after MRSA was isolated.
• Despite improvement in hemodynamics after pericardiocentesis, the patient developed signs of effusive-constrictive pericarditis.
• Treatment included antimicrobial therapy, diuretics, and anti-inflammatory medications (ibuprofen and colchicine).
• The patient’s symptoms improved with medical management, allowing discharge with a plan for continued colchicine and as-needed furosemide.

HCN Medical Memo
This case report serves as a crucial reminder for clinicians to maintain a high index of suspicion for purulent pericarditis in patients with risk factors such as intravenous drug use. Early recognition, prompt pericardial drainage, and appropriate antimicrobial therapy are essential for successful management. The development of effusive-constrictive pericarditis highlights the need for ongoing monitoring and tailored treatment strategies in these complex cases.

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