Contains fulltext :
                  4464.pdf (publisher's version ) (Open Access

Dorp, W.T. van

Meer, J.W.M. van der

Rees, C. van

Thompson, J.

Radboud Repository

PDF hosted at the Radboud Repository of the Radboud University
Nijmegen
 
 
 
 
This full text is a publisher's version.
 
 
For additional information about this publication click this link.
http://hdl.handle.net/2066/14793
 
 
 
Please be advised that this information was generated on 2014-11-11 and may be subject to
change.
Case Report
W. T. van Dorp, C. van Rees, J. W. M. van der Meer, J. Thompson
Meningococcal Pericarditis in the Absence of Meningitis
Summary: A 16 year-old  fem ale presented with cardiac 
tam ponade due to  puru len t meningococcal pericarditis 
without concom itant meningitis or m eningococcaem ia. 
She recovered after aspiration of the pericardial effu­
sion and adm inistration of a high dose of benzylpenicil- 
lin via a continuous infusion.
Zusammenfassung: M eningokokken-Perikarditis ohne  
Meningitis. E in 16 Jahre  altes M ädchen w urde mit 
H erztam ponade bei eitriger M eningokokken-Perikar- 
ditis ohne M eningitis oder M eningokokken-Septik- 
ämie aufgenom m en. N ach A spiration des P erikarder­
gusses und B ehandlung mit hohen D osen Benzylpeni­
cillin über D auerinfusion tra t Heilung ein.
Introduction
Pericarditis is a no t uncom m on complication of m eningo­
coccal meningitis, since it occurs in approxim ately 19% of 
the patients with this disease. Cultures of the pericardial 
fluid usually rem ain sterile (1-3). Isolated puru len t m en­
ingococcal pericarditis in patients w ithout m eningitis or 
meningococcal sepsis is, how ever, exceedingly rare  (4). 
We had a patient w ith isolated purulent m eningococcal 
pericarditis who was cured by pericardial aspiration and 
high doses of benzylpenicillin adm inistered via continu­
ous infusion.
Case Report
A 16-year-old female had had an acute otitis media which 
drained spontaneously two weeks before admission. Seven days 
later she became nauseated and started vomiting. On the tenth 
day she developed a temperature of 40°C without chills. She 
complained of epigastrical pain which was aggravated by breath­
ing and became jaundiced; headache and nuchal rigidity were 
denied. She was admitted to another hospital for suspected 
peritonitis. When, however, ultrasound examination revealed a 
large amount of pericardial fluid, she was referred to our hospi­
tal.
On admission, the patient was jaundiced and critically ill but 
alert and fully oriented. There was no nuchal rigidity or papil­
lary oedema, and on neurologic examination no relevant abnor­
malities were found. The blood pressure could not be measured, 
the pulse rate had risen to 130 beats/min and the central venous 
pressure was greatly elevated. Her temperature was 36.8°C. The 
right tympanic membrane was dull without signs of active in­
flammation. The heart was enlarged; no murmur or friction rub 
could be heard. The lungs were clear. The liver was enlarged 
4 cm below the right costal margin and tender. An electrocar­
diogram showed sinus tachycardia and ST elevation in leads I, 
II, a Vf and V2-V 6. Echocardiography revealed a massive peri­
cardial effusion. Since neurologic examination showed no symp­
toms of meningitis, a lumbar puncture was not performed.
Shortly after admission, 800 ml of pericardial fluid containing 
70 g protein/1 were aspirated. A Gram stain showed gram-nega­
tive diplococci and a culture yielded Neisseria meningitidis, sero- 
group C. Blood cultures remained sterile. Aspiration of the 
pericardial fluid led to a dramatic improvement in the patient’s 
clinical state. Vomiting stopped and jaundice disappeared. The 
meningococcal infection was treated with 12 million U of ben­
zylpenicillin per day administered by continuous infusion which 
resulted in a concentration of 10 U/ml in the serum and 9 U/ml 
in the pericardial fluid. Initially 2 g of cefotaxime were adminis­
tered intravenously four times a day, because the results of the 
Gram stain suggested the possibilities of an infection with a (3- 
lactamase-producing gonococcus. However, when the results of 
the pericardial fluid culture were available and negative for this 
microorganism, cefotaxime was discontinued. The patient be­
came afebrile on day 2. The pericardial drain was then removed 
because fluid production had stopped. However, on day 4 tem­
perature started to fluctuate between 38°C and 39°C (Figure 1).
Day of hospitalisation
Figure 1. Course of temperature during hospitalisation. 
Benzylpenicillin was given at a dose of 12 million U/day; 
cefotaxime at a dose of 4 x 2  g i.v.
A chest X-ray revealed an increasing amount of pleural fluid. 
The ESR rose to 50 mm but the leukocyte count was not elevat­
ed. C3, C4 and CH50 levels, which had been diminished on ad­
mission, became normal on day 6. During hospitalization, no 
immune complexes were detected in the serum. Because of in­
creasing pericardial fluid, another pericardiocentesis was per­
formed on day 6, but only a small amount of fluid containing 
43 g protein/1 could be aspirated; a Gram stain revealed no mi­
croorganisms and the culture remained sterile. At this stage we 
concluded that the clinical picture was most probably due to an 
immunological process.
Without additional measures the patient became afebrile on day 
14, and the pericardial and pleural fluids disappeared. On day 
21, the benzylpenicillin was stopped. On day 23 the patient was
Received; 30 July 1986/Accepted 10 November 1986
W. T. van Dorp, M. D ., J. W. M. van der Meer, M. D., J. Thompson, 
M. D ., University Hospital, Dept, of Infectious Diseases, Building 1, 
C5-P P. O. Box 9600, NL-2300 RC Leiden;
C. van Rees, M. D ., University Hospital, Dept, of Cardiology, Build­
ing 1, C5-P, P. O. Box 9600, NL-2300 RC Leiden.
Infection 15 (1987) Nr. 2 © MMV Medizin Verlag GmbH München, München 1987 29 ! 109
W . T. van Dorp et al.: Meningococcal Pericarditis
discharged in good condition. D uring a follow-up of m ore than 
one  year she rem ained well w ithout signs of pericardial constric­
tion .
Discussion
Pericarditis caused by N. meningitidis is uncom m on since 
few er than 3%  to 4% of the cases of bacterial pericarditis 
can  be attributed to this microorganism (5, 6). Usually it 
occurs in patients with meningococcal meningitis (1). 
H ow ever, in 1971 a case of purulent m eningococcal peri­
carditis w ithout meningitis o r m eningococcaem ia was re­
p o rted  (7). The primary form without m eningitis or m en­
ingococcaem ia is deemed to be exceedingly rare (4, 7, 
8 ). In  our patient pericarditis was possibly due to  bacter- 
aem ia during otitis media two weeks before  admission.
M eningococcal pericarditis is usually caused by N. m enin­
gitidis serogroup C, as was the case in our patient. The 
predom inance of this serogroup may reflect the inability 
o f  the host to clear this microorganism from  the pericardi­
a l cavity (9).
Cardiac tam ponade resulting from  meningococcal peri­
carditis can be treated by pericardiotom y or pericardecto­
m y (9). However, for our patient simple pericardiocente­
sis together with a high dose of benzylpenicillin adminis­
te red  by continuous infusion proved to be adequate. Con­
tinuous infusion was considered necessary in order to 
m aintain a high concentration of penicillin at the site of 
infection. This regimen yielded drug levels in the peri­
cardial fluid equivalent to serum  levels. In  addition,
continuous infusion com pensates fo r the  short half life 
and the short postantibiotic effect o f penicillin (10). 
D uring antibiotic trea tm ent, serous pericarditis devel­
oped. This is no t an uncom m on com plication of m eningo­
coccal meningitis (1, 11, 12). It has been  suggested that 
such an effusion is initially puru len t bu t is rapidly steril­
ized by antibiotic treatm ent (2). A n im m unological m ech­
anism could also account fo r this com plication (7, 13). 
O ur patient exhibited norm al com plem ent levels during 
the serous pericarditis; no im m une com plexes could be 
detected in the serum . H ow ever, the relapse of fever and 
the increasing am ount of sterile pleural fluid are com pat­
ible with an immunological cause. O pinions on corticoste­
roid therapy for serous pericarditis are  controversial (1, 
12). O ur patient recovered com pletely w ithout any fur­
ther therapy.
Addendum
Recently we observed a second patien t w ith a clinical dis­
ease identical to the one described above. This 57 year old 
m an was adm itted because of fever, chills and severe abdo­
minal pain. A n extensive pericardia] effusion was found, 
tha t was drained because of pericardial tam ponade. From  
the pericardial fluid a Neisseria m eningitidis group C was 
cultured. B lood clutures rem ained sterile . There were no 
o ther signs of meningococcal in fec tion , especially not in the 
CNS. The patien t was trea ted  w ith 12x 1()6U of benzylpeni­
cillin by continuous infusion for 14 days. O n the 5th day he 
developed a serous effusion in the left p leural cavity. O ther­
wise the clinical course was uneventful and the patient re­
covered completely.
Literature
1. Morse, J. R„, Oretsky, M. J., Hudson, J. A.: Pericarditis as a com­
plication of meningococcal meningitis. Ann. Intern. Med. 74 (1971) 
212-217.
2. Jones, C.: Pericarditis complicating a case of meningococcal menin­
gitis. Br. Heart. J. 39 (1977) 107-109.
3. Lipton, H.: Pericarditis complicating meningococcic infection in a 
case treated with sulfadiazine. Conn. Med. 15 (1951) 480-483.
4. Thompson, D . G., Pease, C. T., Howard, A. J.: Meningococcal 
pericarditis without meningitis. Br. Med. J. 2 (1977) 1330-1331.
5. Boyle, J. D., Pearce, M. L., Guze, L. B.: Purulent pericarditis; re­
view of literature and report of eleven cases. Medicine 40 (1961) 
119-114.
6. Rubin, R. H., Moellering, R. C.: Clinical, microbiologic and thera­
peutic aspect of purulent pericarditis. Am. J. Med. 59 (1975) 68-78.
7. Beal, R., Ustach, T. J., Ferker, A. D.: Meningococcemia without 
meningitis presenting as cardiac tamponade. Am. J. Med. 51 (1971) 
659-662.
8. Herman, R. A., Rubin, H. A.: Meningococcal pericarditis without 
meningitis presenting as tamponade. N. Engl. J. Med. 290 (1974) 
143-144.
9. Blaser, M. J., Reingold, A. L., Alsever, R. N ., Highfower, A.:
Primary meningococcal pericarditis; a disease of adults associated with 
serogroup C Neisseria meningitidis. Rev, Infect. Dis. 6 (1984) 625-632.
10. Bundtzen, R. W., Gerber, A. tf ., Cohn, D . L., Craig, W. A.: Post­
antibiotic suppression of bacterial growth. Rev. Infect. Dis. 3 (1981) 
28-37.
11. Penny, J. L., Grace, W. J., Kennedy, R. J.: Meningococcic 
pericarditis: a case report and review of the literature. Am. J. Cardiol. 
18 (1966) 281-285.
12. Pierce, J., Cooper, E. B.: Meningococcal pericarditis. Arch. In­
tern. Med. 129 (1972) 918-922.
13. Chow, A. W., Culver, B., Yoshikawa, T. T., Guze, L. B.: Primary 
meningococcal pericarditis presenting with tamponade. Chest 67 (1975) 
611-613.
110 / 30
Infection 15 (1987) Nr. 2 © MMV Medizin Verlag GmbH München, München 1987


Meningococcal pericarditis in the absence of meningitis

Abstract

Similar works

Full text

Available Versions

Radboud Repository

NARCIS