A Rare Pericardial Milky Tamponade in the ER: When Images Speak Louder Than Words.

We present a rare case in modern medical history, and only the fourth example,1)2)3) of Streptococcus Constellatus purulent pericardial tamponade.

A 73-year-old immunocompetent man whose informed consent was obtained presented to our center with cardiac tamponade after being admitted for cervical laminectomy in the context of acute exacerbation of known cervical spondylotic myelopathy.

A transthoracic echocardiogram (Figure 1) showed clear signs of pericardial tamponade.

Figure 1

Imagiological characterization of the pericardial effusion and drained fluid having a milky appearence.

On the left side are chest CT images of the patient. In the upper panel, an enormous loculated PE is shown with dimensions of approximately 13 × 7 cm. In the lower left panel is the post-pericardiocentesis CT image showing resolution of the PE and a clear view of the RV. (A-F) Images present echocardiographic images of the patient’s large PE, showing echocardiographic signs suggestive of cardiac tamponade: a complete collapse of right heart chambers and IVC plethora (F). (E) The apparency of the effusion is illustrated as a large heterogeneous and loculated effusion with unusual appearance without evidence of fibrin material. In the right image is the milky appearance of nearly one liter of drained effusion.

CT: computed tomography, IVC: inferior vena cava, LA: left atrium, LV: left ventricle, PE: pericardial effusion, RA: right atrium, RV: right ventricle.

*Pericardial effusion.

Figure 1 demonstrates the purulent pericardial fluid drained through a subxiphoid pericardiocentesis, a challenging procedure made possible via injection of heparinized saline solution into the pericardial space to dilute the purulent content. A total of 750 mL of fluid was drained. A pericardial drain was left in place, and intermittent drainage combined with antibiotic therapy was performed until the effusion has resolved, avoiding the need for surgical intervention.

Afterward, etiologic evaluation of the primary source of this Streptococcus Constellatus pericarditis infection was performed. A plausible explanation points to post-operative cervical collection, documented in magnetic resonance images, as the initial infection site and that contiguously spread to the heart.

The Streptococcus anginosus group (SAG) includes three commensal species of the respiratory, digestive, and reproductive tracts that have been linked to pyogenic infections.1)2)3)4) The majority of reported SAG pericarditis cases occurs in immunocompromised people,1) although this was not true for the presented patient.

This remarkable case reinforces the importance of considering opportunistic infectious etiology of cardiac tamponade in a world of increasingly immunocompromised patients.