Purulent Pericarditis

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:
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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
Thanks so much for visiting my blog! Writing and reading posts takes time and we all know that time is precious. You and I will both get much more out of this blog if it leads to dialogue/exchange of ideas. If you found this post useful and wouldn’t mind leaving a brief comment and sharing via email or social media, I would be extremely grateful. My posts are generally written quickly, so if you have any feedback, or find any factual or grammatical errors, please do let me know. Regards, “Dr. Phil”

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