Kuipers, Fred M.

Nixon, Robert K.

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical JournalVolume 8 | Number 3 Article 109-1960Pericarditis As The Presenting Manifestation InSubdiaphragmatic AbscessFred M. KuipersRobert K. NixonFollow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public HealthCommonsThis Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. For more information, please contactacabrer4@hfhs.org.Recommended CitationKuipers, Fred M. and Nixon, Robert K. (1960) "Pericarditis As The Presenting Manifestation In Subdiaphragmatic Abscess," HenryFord Hospital Medical Bulletin : Vol. 8 : No. 3 , 360-362.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol8/iss3/10PERICARDITIS AS THE PRESENTING MANIFESTATION IN SUBDIAPHRAGMATIC ABSCESS FRED M . KUIPERS, M.D.* AND ROBERT K . NIXON, M.D.* Pericarditis is a relatively uncommon thoracic complication of subdiaphragmatic abscess. The following case is considered worthy of reporting inasmuch as the findings of pericarditis preceded other diagnostic signs of the subdiaphragmatic abscess. CASE REPORT A 35 year old white female entered the Henry Ford Hospital on March 22, 1959, with a history of severe diarrhea, intermittent fever and weight loss of 50 pounds in an eight month period. Anorexia, abdominal cramping and swelling, redness and tenderness of the knees and wrists had also been present. The patient had received cortisone therapy and blood transfusions prior to her transfer here from a Lansing hospital. On physical examination, she was a poorly nourished, chronically i l l , white female appearing toxic and wasted. The temperature was 103 degrees, blood pressure 90/60; examination of the abdomen revealed hyperactive bowel sounds and the stool guiac on rectal examination was 3-I-. Extensive laboratory studies were performed including repeated stool examinations for ova, parasites, agglutination studies for typhoid, paratyphoid and shigella, all of which were negative. Sigmoidoscopy and colon x-rays revealed changes characteristic of chronic ulcerative colitis. Following a period of medical management which included Barron tube feedings, asulfidine and various anti-diarrhea agents, the patient gained some 20 pounds, but continued to have diarrhea up to 6 to 10 stools daily and manifested continuing daily temperatures up to 102 degrees. On June 11, a total colectomy and ileostomy was performed; at operation, a small perforation of the descending colon with a walled-off abscess was found. Post-operatively, the patient was carried on a program which included penicillin, streptomycin and Chloromycetin. She developed an acute hepatitis which was thought to be of the homologous serum type inasmuch as she had received transfusions 2 to 3 months prior to the onset of her jaundice. On June 25, the 14th post-operative day, at a time when the jaundice was clearing, a loud, well localized, to and fro friction rub was heard in the third interspace at the left sternal border. The patient's condition, otherwise seemed unchanged. A temperature of 100.8 degrees was present, but this was in the range which she had displayed during her post-operative period. Laboratory studies revealed a blood urea nitrogen of 58 mgm., serum creatine of 2.5 mgm. The blood urea nitrogen had fallen from a previous level of 78 mgm. per cent on June 22, and continued a steady decline over the ensuing 2 week period. Electrocardiographic studies revealed ST segment elevations in Leads 1, 2, AVE, V3-4 and 5. On July 8, 14 days following the onset of the friction rub, dullness and decreased breath sounds developed at the right lung base posteriorly and on fluoroscopic examination, a small right pleural * Division of General Medicine. 360 Subdiaphragmatic A bscess effusion and decreased right diaphragmatic movement were noted. On July 9, 800 cc. of purulent material was drained from the right subphrenic space through a sub-costal abdominal incision. At the time of surgery, a small perforation was inadvertently made in the small bowel and this was promptly repaired. On July 14, a diagnosis of thromboplebitis was made and the patient was placed on anti-coagulant therapy. She appeared to be improving post-operatively but expired suddenly and unexpectedly on July 26, 1959. At autopsy, no anatomical cause was disclosed for her sudden death which was concluded to have been due to a probable sudden cardiac arrhythmia or arrest. Final anatomical diagnosis included: chronic ulcerative colitis, idiopathic; post-operative total colectomy and ileostomy; gangrene of the small intestine. Micro-scopic evidence of a subsiding pericarditis was also evident. DISCUSSION A review of 90 cases of subdiaphragmatic abscess at the Henry Ford Hospital from 1955 to 1959, disclosed no other instance of complicating pericarditis. Harley' found no pericarditis in 182 cases of subdiaphragmatic abscess. However, in a later series of 54 patients,^ the same author reported 4 patients with pericarditis secondary to suppurative pulmonary complications of subdiaphragmatic abscess. A review of 134 cases of subdiaphragmatic abscess at the Mayo Clinic^ revealed com-plications, mainly thoracic, in 77% but, pericarditis was not numbered among these. Ochsner and Debakey" found a 5% incidence of pericarditis in 1,380 cases of subdiaphragmatic abscess. In their series, other thoracic complications included perforation of the diaphragm (27.7%), empyema (17.8%) and bronchopleural fistula (10.5%). It should be noted that pleural effusion may be an early sign of subdiaphragmatic abscess' and that recurrent pericardial effusion' as well as actual rupture into the pericordium by the subphrenic abscess' may occur as com-plications of the latter disease. Other authors" have confirmed a 2-5% incidence of pericarditis as a complica-tion in subdiaphragmatic abscess. Two comments with reference to our case would seem to be pertinent. First, the possibility of a uremic etiology for the pericarditis might be suggested by the moderate azotemia which was initially present. The Hkelihood of this appeared to be minimal both because of the relatively low level of nitrogen retention and the fact that the latter disappeared while the pericarditis persisted and, in fact, seemed to increase in degree. Secondly, it may be speculated that the antibiotics, which our patient was receiving, may well have played a role in masking or delaying the appearance of the more classic signs of the underlying disease. SUMMARY A review of 90 cases of subdiaphragmatic abscess at the Henry Ford Hospital, as well as a general survey of the literature, suggests that pericarditis is an uncommon complication. This report deals with a case which was unique in that the findings of pericarditis preceded by some two weeks the diagnostic signs of a subdiaphragmatic 361 Kuipers and Nixon abscess. It is our wish to call attention to the fact that a pericardial friction rub may be the presenting sign of an underlying subdiaphragmatic abscess. BIBLIOGRAPHY 1. Harley, H. R. S.: Subphrenic abscess. Thorax 4:1, 1949. 2. Harley, H. R. S.: Subphrenic abscess, with particular reference to spread ot infection; Hunterian lecture, Ann. Roy. Coll. Surgeons England 17:201, 1955. 3. Berens, J. J., Gray, H. K., and Dockerty, M. B.: Subphrenic abscess, Surg., Gynec, & Obst. 96:463, 1953. 4. Ochsner, A., and DeBakey. M.: Subphrenic abscess, Internat. Abstr. Surg. 66:426, 1938. 5. Hochberg, L. A.: Diagnostic criteria for subphrenic abscess based upon study of 139 cases, Ann. Int. Med. 17:183, 1942. 6. Boyd, D. P.: Intrathoracic complications of subphrenic abscess, J. Thor. Cardiov. Surg. 38:771, 1959. 7. Wetterfors, J.: Subphrenic abscess. Acta chir. scandinav. 117:388, 1959. 8. Speirs, A. L.: Pericardial effusion as sequel to subphrenic abscess, Brit. M. J. 1:679, 1951. 9. Meyer, N. C : Rupture of subphrenic abscess into pericardium, Ann. Surg. 29:148, 1949. 362 

Pericarditis As The Presenting Manifestation In Subdiaphragmatic Abscess

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