I recently received an email from a friend, a physician in Mozambique. She had a puzzling clinical case which she wanted assistance with, so I asked her if I could put it on my blog. She agreed.
Her patient was a 28 year old man, HIV negative, hospitalized with the diagnosis of purulent pericarditis. He had a history of 7 months of dyspnea, fatigue, chest pain, and weight loss. He denied fever, cough, diaphoresis, or edema. He had no history of TB.
He worked as a teacher, did not smoke, and previously drank beer on the weekends. On physical examination, his vital signs were normal. He was cachectic, with elevated JVP, bilateral pleural effusions, hepatomegaly of 3 cm and no edema. Thoracentesis of the right side showed yellow fluid. Lung sonography demonstrated a septated pleural effusion in multiple sites on the left side. Echocardiography showed a pericardial effusion with fibrin and thickened pericardium. Pericardicentesis showed yellow fluid, purulent. Plans were for a pericardial window. He was clinically stable. The doctors started treatment for TB because their first diagnosis was TB (pleural and pericardial). After that he received IV antibiotics. The pleural effusion on left side seemed to be old, and the pericardial effusion seemed to be old. My friend’s question was how TB pericarditis progressed to purulence without clinical signs of a new infection?
Please leave comments below:
My main suggestion for my friend was that they pursue a microbiologic diagnosis with gram stains, cultures, AFB smear, culture, biopsy to be sent for pathology, etc
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