Overview.
Septic pericarditis is an acute purulent inflammation of the pericardium caused by purulent bacteria. It includes acute and chronic inflammation of the pericardium’s visceral and mural layers, and its incidence has decreased significantly due to the widespread use of antibiotics. Most patients are young children or adolescents, and it is rare in the elderly. Inadequate treatment of purulent pericarditis can lead to complications such as pericardial effusion and pericardial tamponade.
Causes
Septic pericarditis is caused by bacterial infection. Early stage is pericardial congestion, edema, massive leukocyte infiltration, fibrin deposition, which may invade the myocardium causing purulent inflammation of the myocardial surface. Intrapericardial exudate contains polymorphonuclear leukocytes in the form of rice pudding juice or pus and blood, and acute pericardial tamponade can occur when the exudate is abundant and rapid. In the acute onset of proper treatment, the inflammation can subside and healed, otherwise the condition can be delayed into chronic pericarditis. The etiology is as follows:
1. Can be caused by trauma to the pericardium direct contamination of the onset.
2. Secondary to sepsis or septicemia caused by acute infection of skin, soft tissue, bone marrow, etc.
3. Some of them are secondary to subphrenic septic infections. The causative organisms are staphylococcus, streptococcus, pneumococcus and other common.
Symptoms
The onset of the disease is characterized by chills, fever, excessive sweating, lethargy, loss of appetite, anemia, body aches and pains, and other signs of systemic infection, which may be accompanied by varying degrees of panic, shortness of breath, coughing, inability to lie down, and retrosternal pain and discomfort.
Examination
1. Physical signs
Physical examination, early pericardial friction can be heard in the precordial region, with the increase of pericardial effusion, the heart boundary is enlarged, apical beat disappears, heart sound is distant, pulse pressure becomes narrow, heart rate accelerates, jugular vein is furious, liver is large, and so on. In the presence of pericardial effusion there may even be dyspnea, telangiectasia, shallow breathing, pallor, or even cyanosis. Severe pericardial effusion may lead to pericardial tamponade, obvious tachycardia, drop in blood pressure, decrease in pulse pressure and obvious increase in venous pressure, and even shock.
2. Laboratory examination
Peripheral whole blood cell analysis shows elevated leukocytes and neutrophils; markedly elevated C-reactive protein; accelerated blood sedimentation and other inflammatory reactions.
3. X-ray
Pericardial effusion sign, flask-like cardiac shadow, weakened heart beat. The shadow of the heart can be seen enlarged to both sides, and the heart beat is weakened or disappeared.
4. Electrocardiogram
ST-segment elevation in the standard limb leads is bowed back and downward, and ST-segment depression and T-wave inversion in the aVR leads. One to several days later, the ST segment returns to the baseline, T wave depression and inversion appear, and the T wave gradually returns to normal for several weeks to months; each lead shows QRS wave group low voltage, and electrical alternans can be seen when there is a lot of seepage; there is no pathologic Q wave, and there is no prolongation of the QT interval; sinus tachycardia is often present.
5. Echocardiography
Echocardiography is simple and easy to diagnose pericardial effusion, rapid and reliable, with a large amount of fluid reflection wave in the pericardial cavity. Right atrium and right ventricle collapse in diastole during pericardial tamponade; right ventricular internal diameter increases and left ventricular internal diameter decreases during inspiration.
6. Magnetic resonance examination
It can indicate the distribution of pericardial effusion.
7. Pericardiocentesis
Biological (bacterial, fungal, etc.), biochemical, and cellular classification tests can be performed on the extracted fluid. The presence of purulent fluid is diagnostic, and the perforated material is sent for smear and bacterial culture to identify the causative organisms.
Diagnosis
According to the clinical manifestations and auxiliary examination, consider the possibility of this disease. Pericardiocentesis or windowing is performed to drain purulent pericardial effusion, and bacteria can be found in the smear and culture of the puncture fluid, which can confirm the diagnosis of the disease.
Treatment
1. General treatment
Bed rest, avoiding exertion, supplementing nutrition, inhaling oxygen and other basic treatments.
2. Systemic treatment
Considering that oral antimicrobials can not inhibit the pathogenic bacteria, therefore, a sufficient amount of effective antibiotic treatment should be given intravenously. If the causative organisms are not clearly identified, broad-spectrum antibiotics should be given as much as possible, and after the causative organisms are clearly identified, targeted drugs should be given to the causative organisms. At the same time to strengthen the systemic support, a small number of transfusion of fresh blood, high protein, high vitamin diet, to maintain electrolyte balance, if necessary, physical hypothermia.
3. Pericardiocentesis
Pericardiocentesis is suitable for pus drainage and antibiotic injection into the pericardial cavity in the early stage of the disease when the exudate is still thin. Pus is drained and antibiotics are injected every time. For safety, pericardiocentesis can be performed under electrocardiographic and ultrasound monitoring.
4. Pericardiotomy and drainage
It is suitable for patients who have been treated with repeated pericardiocentesis without significant improvement.
5. Partial pericardiectomy
Suitable for patients who have been ill for a long time and have developed chronic constrictive pericarditis.
Prognosis
The prognosis of septic pericarditis is related to the severity of pericarditis, pre-existing diseases, original cardiac function and other factors. The prognosis is better in patients with good pre-existing heart function than in patients with pre-existing heart failure. The more severe the pericarditis, the worse the prognosis. Patients with chronic viral pericarditis have a poor prognosis and tend to die of heart failure.
Prevention
Avoiding contact with infectious agents and paying attention to personal and dietary hygiene are important in preventing idiopathic pericarditis. At the same time, early detection and early treatment are important to improve the prognosis of idiopathic pericarditis.