LETTERS Critical Care and Resuscitation • Volume 9 Number 1 • March 2007 106 Crit Care Resusc ISSN: 1441-2772 5 March 2007 9 1 107- 108 ©Crit Care Resusc 2007 www.jficm.anzca.edu.au/aaccm/ journal/publications.htm Letters Finding pneumo: purulent pericarditis presenting with pulsus paradoxus Christopher C Blyth, Indira Jayakumar, Peter Richmond, Andrew M Bullock and Simon J Erickson T O THE EDITOR: In the pre-antibiotic era, purulent pericarditis was a disease predominantly affecting children and young adults and was commonly associated with pneumonia or empyema. 1 With therapeutic advances, the incidence and mortality of purulent pericarditis have decreased, and it is now most often seen in the elderly, the ill and the immunosuppressed. 2 We report a 16-month-old girl with recurrent otitis media and mild pulmonary valve stenosis who presented with a 4-day history of fever, lethargy and anorexia. She had previously received Haemophilus influenzae type b and meningococcus type C vaccines but not pneumococ- cal vaccines. Oral amoxycillin and clavulanic acid had been commenced to treat acute otitis media 2 days before the current presentation. On presentation, she had tachycardia and tachypnoea. Blood pressure was 98/65 mmHg, and peripheral per- fusion was poor. Examination showed significant hepatomegaly but no abnormality on auscultation. Labo- ratory tests showed acidaemia (pH, 7.06), with a serum lactate concentration of 9.3 mmol/L, neutrophilia (neu- trophil count, 28  10 9 /L), coagulopathy (international normalised ratio, 3.7; activated partial thromboplastin time, 50 s), transaminitis (serum alanine aminotransferase concentration, 3591 U/L), and normal renal function. Anteroposterior chest x-ray showed a normally sized cardiac silhouette (cardiothoracic ratio, 55%) without focal changes. Despite endotracheal intubation, ventilation, fluid resus- citation and inotropic support, tachycardia persisted, and hypotension worsened (70/50 mmHg). Pulsus paradoxus was identified on continuous blood pressure recording, with a difference of 15 mmHg between inspiration and expiration. Elevated central venous pressure (23 cmH 2 0) was noted following insertion of a right internal jugular central venous catheter. The patient suffered a bradycardic arrest, requiring cardiopulmonary resuscitation for 2 min- utes. Following this, electrocardiography demonstrated sinus tachycardia with widespread ST elevation. A transthoracic echocardiogram showed a large pericar- dial effusion. There was evidence of tamponade with diastolic right atrial and ventricular collapse and generalised marked systolic dysfunction. Some fibrinous strands were seen within the effusion. Needle pericardiocentesis was performed using the standard approach, and 55mL of purulent fluid was drained, with marked improvement in haemodynamic parameters. Microscopic examination of the fluid revealed polymorphonuclear leukocytosis and gram- positive diplococci. Streptococcus pneumoniae antigen was demonstrated on latex particle agglutination. However, cultures of blood and pericardial fluid remained negative. The infant was treated with intravenous antibiotics for 23 days. Her intensive care stay was complicated by acute lung injury, acute renal failure requiring peritoneal dialysis, and hepatic dysfunction. Daily echocardiograms revealed no reaccumulation of pericardial fluid, with no Doppler evidence of constrictive pericarditis. Investigations to iden- tify an underlying immunodeficiency gave negative results. She subsequently made a full recovery. This case highlights the difficulty of diagnosing purulent pericarditis in young children, who commonly lack the classic symptoms and signs. A high degree of clinical suspicion is required in children with fever and haemody- namic compromise who fail to respond to appropriate therapy, to enable early management. Christopher C Blyth, Paediatric Infectious Diseases Fellow 1 Indira Jayakumar, Paediatric Intensive Care Specialist 2 Peter Richmond, Senior Lecturer, School of Paediatrics and Child Health, and Paediatric Immunologist 3 Andrew M Bullock, Paediatric Cardiologist 3 Simon J Erickson, Paediatric Intensive Care Specialist 3 1 Sydney Children’s Hospital, Sydney, NSW. 2 Kanchi Kamakoti Childs Trust Hospital, Nungambakkam, Chennai, India. 3 Princess Margaret Hospital for Children, Perth, WA. Correspondence: christopher.blyth@sesiahs.health.nsw.gov.au References 1. Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis: an 86 year autopsy experience in 200 patients. Am J Med 1977; 63: 666-73. 2. Go C, Asnis DS, Saltzman H. Pneumococcal pericarditis since 1980. Clin Infect Dis 1998; 27: 1338-40. ❏ Correction Re: “Notable Australian contributions to the management of ventilatory failure of acute poliomyelitis. With special reference to the Both respirator and Dr John A Forbes”, by Ronald V Trubuhovich, in the December issue of the Journal (Crit Care Resusc 2006; 8: 383-393). In the caption to Figure 1 on page 384 and the Acknowledgements section on page 392, the Ny Carlsberg Glyptotek, København, was incorrectly referred to as the Ny Carlsbad Glyptotek. ❏