Beck, P.D.

Kahn, L.B.

English

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1450 TYD KRIF VIR GE 'EESKU DE 29 ovember 1969PURULENT PERICARDITIS: REPORT OF A CASE*P. D. BEcK,t M.B., CH.B. (CAPE TOWN), M.MED. (PAED.) (CAPE TOWN) A 0 L. B. KAH ,t M.B., B.CH. (R 'D),M.MED. (PATH.) (CAPE TOWN), Departments of Paediatrics and Pathology, University of Cape Town and GrooteSchuur Hospital, Observatory, CapePurulent pericarditis is a rare complication of acute bac-terial menjngitis. The cause of the menjngitis and of thepericarditis in these instances is usually eisseria menin-gitidis. We wish to report a fatal ca e of Haemophilusinflllenzae meningitis complicated by purulent pericarditis.CASE REPORTC.B.. a 10-month-old Coloured male infant, wa admittedto G roote Schum Hospital with a 2-day history of rest·lessness and irritability. On examination, he wa found tohave a tiff neck. A lumbar puncture was performed andthis howed purulent fluid, which had a protein contentof 40 mg./lOO m!., normal concentration of sugar, and acell count of 378 polymorphonuclear leucocytes and 42Iymphocytesjcu.mm. Haemophilus inflllenzae was cul-tured from the cerebrospinal fluid and thjs organi m wasensitive to chloramphenicol. erythromycin, tetracyclineand treptomycin. Initially, he was treated with penicillin,chloramphenicol and Gantrisin. One week later, when theresults of the culture became known, this regimen waschanged to chloramphenicol and treptomycin. A chestX-ray taken 24 hours after admission showed a largecardiac hadow (Fig. J). The chjld was extremely ill witha pulsus paradoxus, raised jugular venous pressure and5-finger enlarged, tender liver. The ECG showed ST ele-vation in the chest leads.Under ECG monitoring, 52 m!. of seropurulent fluidwas aspirated from the pericardial sac. On the followingtwo days, 30 and 40 ml. respectively of purulent fluidswere a pirated. 0 more fluid was obtained on sub-equent attempts at aspiration. At this stage, there was amarked improvement in the child s condition except forthe development of a small right-sided pleural effusionon the sixth day. Forty ml. of straw-coloured fluid wasaspirated from the pleural sac. The pericardial and pleuralaspirates contained pu cells, but no organisms were cul-tured. Blood cultures were also negative.Twenty days after admission, another chest X-ray wastaken (Fig. 2). Thi showed a reduction in the size of thecardiac hadow. Two day later the child became ex-tremely dyspnoeic, developed a severe tachycardia withpulsu paradoxus, and died.Postmortem FindingsThe heart (170 G) appeared to be a very large organ(Fig. 3). An extraordinary picture was seen when thepericardial sac wa opened (Fig. 4). The visceral andparietal layers of the pericardium were separated by in-spissated yellowish-green purulent material measuring be-tween 1 and J'5 cm. in thickness and causing compressionof the heart it elf. The myocardium howed generalizedpallor. Histologically, the presence of a fibrino-purulentexudate in the pericardial ac was confirmed. The exudate*D3Ie received: 2 M3Y 1969.t Present 3Jdre~s: 40 Oasim. Pearson treet. POrl Elizabeth.~PrC' eot addres : John J. Cochran Veterans Hospital. SI Louis, Mi~souri.SA.was 'undergoing organization adjacent to the myocardium.No organisms were detected on direct microscopicalexamination, nor were any cultured from the purulentmaterial.A fairly recent antemortem thrombus about 4 cm. inlength wa present in the right internal jugular vein.The right lung (86 G) showed a fibrinous exudate onthe pleural surface of the lower lobe. The liver (385 G)showed the effects of severe pas ive venous congestion,viz. centrilobular zonal congestion with zonal necrosisand fatty change in liver cells. The brain (900 G) show-ed no evidence of meningitis macroscopically or micro-scopically.There was no evidence of spread of infection of thefollowing organs examined microscopically: Ijver,thyroid, kidneys, brain, pancreas, spleen and adrenals.The final anatomical diagnoses in this case were: peri-carditis causing tamponade following Haemophilus in-fluenzae merungitis, right-sided pleurisy, thrombosis ofthe right internal jugular vein and chronic passive venouscongestion of the liver. The menjngitis had completelyresolved. .'Fig. J. X-ray taken 24 hour after admis ion howingcardiac hadow.29 lovember 1969 S.A. MEDICAL JOUR AL 1451Fig. 2. X-ray taken 20 days after admission showingreduction in size of cardiac shadow.Fig. 3. Unopened pericardial sac showing apparent grosscardiomegaly.Fig. 4. Vertical section through heart showing separationof the pericardial layers by inspi sated exudate.01 C SSIONPurulent pericarditis as a complication of acute menin-gitis is a distinct rarity. In the 8-year period 1959 - 1966inclusive, there were 17 cases of purulent pericarditis atthe Red Cro Children's Hospital, and 7 in the children'medical wards at Groote Schuur Hospital. Only one ca ewas preceded by acute meningitis. In a review of 425 caseof purulent pericarditis collected from the world litera-ture up to March 1969, Boyle et al.' found that 4% werethe result of infection by neisseria meningitis. Herrick'and Smithburn et al.' reported meningococcal pericarditisin 4 - 6°~ of cases of meningococcal meningitis duringepidemics of this disease.Haemophilus pericarditis accounted for only 9 of the425 cases in Boyle's review, and in most of these ca esthe primary focus of infection was in the respiratory tract.In some case the pericardial involvement wa consideredto be the result of direct pread from contiguous infectedlung. In other cases, haematogenous spread to thepericardium was postulated. In the case reported here,pericarditis developed 3 days after the onset of acutemeningitis. The failure to isolate the organism from thepericardial aspirate is not surprising, in view of theantibiotic therapy which had already been administered.According to Boyle, purulent pericarditi is diagno edin a low percentage of cases during life. The clinicalfeatures include increased heart size, pericardial frictionrub, decreased intensity of heart sound. rai ed jugular1452 S.A. TYDSKR1F VIR GE EESKU DE 29 overnber 1969venous pressure, enlarged tender liver and a pulsus para-doxus. Several newer techniques are now being used andthese should increa e the percentage of cases diagnosedduring life. These techniques include radio-isotope heartscanning with radioactive 1311 tagged to human serumalbumin or angiocardiography to outline the intracavitarycardiac blood pool and demonstrate its relationship tothe radiographic cardiac outline.' The risk associated withthese procedures is minimal.Management of purulent pericarditis is a difficult prob-lem. Despite antibiotic therapy, a high mortality rate stillprevail. There were 19 deaths in the 24 cases in childrenseen at the Red Cross Children's Hospital and GrooteSchuur Ho pitaI. Early urgical drainage is important iffatal tamponade is to be avoided in ca es which fail torespond to medical therapy.SUMMARYAn unusual case of suppurative pericarditis complicatingHaemophilus influenwe meningitis in an infant is described.Despite early pericardial aspirations, a fatal cardiac tamponadedeveloped. There is a significant mortality even with antibiotictherapy. Early diagnosis and adequate surgical drainage isimportant in cases which fail to respond promptly to antibiotictherapy.We wish to thank Dr R McDonald, senior paediatrician, forvaluable advice; Prof. J. D. L. Hansen for details of the RedCross Hospital records; Prof. J. G. Thomson for the pathologyreport; and Dr J. G. Burger, Medical Superintendent of GrooteSchuur Hospital, for permission to publish the case.REFERENCESI. Boyle, J. D., Peake, M. L. and Guze, L. B. (1961): Medicine (Balti-more). 40. 119.2. Herrick, W. W. (1918): Med. Clin. N. Amer., 2, 411.3. Smith burn. K. C., Kempf. G. F .. Zerfas, L. Y. and Gelman. L. H.(1930): J. Amer. Med. AssQC.. 95, 776.4. Folger, G. M. (1966): Clin. Pediat., 5, 225.IN MEMORIAMJACOB WOLF HARRIS. M.B., Ch.B. (Edin.). D.O. (Oxon),D.O.M.S. (R.C.P. Lond., RC.S. Eng.)Dr E. Miller, of Port Elizabeth, writes:On 24 June 1969 Dr Jacob Wolf Harris, aged 70 years,passed away at Port Elizabeth Provincial Ho pital after along illnes bravely borne. The Ea tern Province lost a fineophthalmologi t-one who haddevoted much of his life to theservice of others. One of hisoutstanding characteristics washis capacity for friendship. Hiscomplete honesty, genuine sin-cerity and sunny dispositionendeared him to many, and hisfriends and colleagues alwaysenjoyed his companionship andkeen sense of humour. He alsohad a deep religious faith,which he lived by in his re-lations with his fellow men.He attended school at Oudts-hoorn, and obtained his M.B.,Ch.B. degree in Edinburgh in1924. Having acquired clinicalexperience in London. Birming-ham, Edinburgh and Vienna,he obtained the degrees ofD.O.M.S. (Eng.) and D.O. D H .(Oxon). With this background r arns .of ophthalmic experience, he started practice in Port Elizabeth.Among his many non-medical activities was his intenseinterest in philately, as a result of which he won the Trophyfor the International Exhibit in Cape Town in 1952, formedical philately of South Africa, at the South African Ter-centenary Exhibition of Stamps. In 1962 and 1967 he wasawarded the Floating Trophy for the best Thematic Exhibit, inPort Elizabeth.He was Vice-President of the Society for the Blind. Alsovery interested in the education of children, he was anHonorary Life Member of the Port Elizabeth Hebrew School.He is survived by his wife and daughter, and by a brotherwho is also a member of the medical fraternity. To them andtheir families we extend our sincerest sympathy.One can conclude by quoting from a letter from an intimatefriend: 'What can I say to you about the loss of a man whowas always to me one of the broadest-thinking people I knew.He combined great intellectual powers with gentleness, andever searching for knowledge with kindness for ani interestin others and their problems. and serious thought processeswith merry laughter and mirth. I think he taught me. by ex-ample, that searching for the truth was of primary import.'JOH ASARJA KEEN, M.B., B.S. (Lond.), ERC.S. (Eng.)Prof. J. Gordon, of Durban, writes:Prof. J. A. Keen, the first Professor of Anatomy at theUniversity of atal, appointed in 1952, died at Southamptonon 7 October 1969. His father, who graduated at Edinburgh,was a medical missionary in China and Professor Keen wasborn in Hong Kong in 1894. He qualified at Charing CrossHospital in 1917.On qualifying, he immediately joined the R.A.M.C. and wasposted to East Africa. Stricken with malaria, he was invalidedto Wynberg Military Hospital. During his convalescence heclimbed Table Mountain which, in view of his subsequentinterest and development of new routes of ascent of themountain, was probably the major factor in leading him ulti-mately to return to settle in Cape Town.After demobilization in Britain, he obtained his F.R.C.S.degree and worked as a surgeon in diseases of the ear, noseand throat in Leicester for 15 years. During his surgicalcareer he published many papers in his subject, .but he resolvedto become an anatomist, and in 1937 his classical work A ShortManual of Regional AnaTomy was published.Following his brother, Dr Paul Keen-the well-knownsurgeon of Johannesburg's on-European Hospital-he cameto South Africa and joined Professor Drennan's departmentas a Lecturer in Anatomy at the University of Cape Town.He later became warden of the Medical Residence at theUniversity. He published many articles in anatomy and revisedthe well-known manual of anatomy by Ellis. incorporatinghis own new dissecting instructions. His revision was a greatsuccess and is stiIJ used widely in schools of anatomy.After his pioneering work in th~ D~partment of Anatomy, heretired in 1958 and was succeeded by his son, Prof. E. . Keen.who is the present Professor of Anatomy of the University ofatal. He continued teaching anatomy after his retirement, atthe medical schools of Cape Town and Stellenbosch andlater abroad at Lausanne and Southampton. He died 'inharness' while teaching a graduate class of 40 students atSouthampton. His death was tragically sudden as he had neverhad a day's illness during the ye3.CS of his 'act.ive retirement'.Professor Keen was a gentle and reserved man with a greatfund of intellectual energy. He spoke French, German andEnglish fluently, and ta'ught himself Portuguese. He had manyhobbie and was a great lover of music. Possibly his mostnota ble extramural interest was mountain climbing, and whilein Cape Town he published an excellent guide to the easierroutes of ascent of Tabl~ Mountain.We extend to his son. Prof. E. . Keen, and to his familyour deep sympathy in th~ir loss.

Purulent pericarditis: Report of a case

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Purulent pericarditis: Report of a case

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