Purulent pericarditis

Inflammatory processes in the pericardium - the pericardial bursa - may have different mechanisms of origin and development, differ in treatment approaches and prognosis. However, purulent pericarditis has the most unfavorable course: many cases of this disease end in death. Specialists call it extremely important to perform timely operative diagnostic measures with further well-thought-out therapy. [1]

Epidemiology

Purulent pericarditis is a rare condition that occurs in less than 1% of patients with cardiac problems. According to Western European estimates, the pathology is most often provoked by staphylococci, streptococci, and pneumococci. Among the associated lesions, empyema and pneumonia are common.

In immunodeficient patients or after thoracic surgical interventions in most cases, Staphylococcus aureus (30%) and fungal infection (20%) are isolated. Anaerobic pathogens may be isolated from the oropharyngeal region.

Infectious agents spread hematogenously, either through the retropharyngeal area, heart valves, or subdiaphragm.

Neisseria meninghitidis is able to affect the pericardium by initiating an immune-associated sterile effusion, or by direct infection and development of a purulent response.

The microscopic pattern in patients with iatrogenic and HIV-associated immune suppression may be more diverse and exotic.

In general, purulent pericarditis is understood as an infectious (more often microbial) exudative inflammation of the pericardium, during the development of which there is an accumulation of exudative pus in the pericardial bursa. Purulent pericarditis in most cases is a secondary disease, which acts as a complication of other cardiovascular, respiratory (pulmonologic), gastroenterologic and traumatic pathologies.

Among other types of pericarditis, the purulent variant occurs in about 8% of cases.

To date, there has been some increase in the total number of pericarditis, and at the same time a decrease in the number of purulent pericardial inflammations.

The disease is characterized by a poor prognosis in case of failure to provide timely medical care, and a fairly good prognosis in case of adequate timely treatment.

Purulent pericarditis is accompanied by the accumulation of exudative pus, both in a separate sinus and in the entire pericardial cavity. At the same time, the volume of exudate can be different - from 100 to 1000 ml. Patients of any age and sex can be ill. [2]

Causes of the purulent pericarditis

Purulent pericarditis is a predominantly secondary disease that develops when some infectious agent - from other foci of infection in the body - enters the pericardial cavity.

Numerous microorganisms found in the environment can act as infectious agents. It can be bacteria, spirochetes, rickettsiae, pathogenic fungi, protozoa and viruses. Infectious agents can have a direct damaging effect on the pericardium, or cause adverse changes in the immune system, which leads to a failure in the body's defense system.

The functionality of the immune system is regulated by endocrine and nervous mechanisms. Numerous stresses and other pathogenetic factors provoke immunity disorders, thereby weakening the defense against the influence of infection. Therefore, very often purulent pericarditis develops against the background of psycho-emotional overload, severe stress.

The body's antipathogenic defense against infectious invasions is carried out by two types of immunity:

• innate immunity is determined by a genetic (hereditary) factor;
• acquired immunity is formed during the life process.

In most patients, purulent process in the pericardium occurs against the background of lung inflammation, pleural empyema, mediastinitis, pulmonary or subdiaphragmatic abscess, endo and myocarditis. In this situation, the pathogen enters the pericardial bursa from nearby anatomical structures.

Sometimes the infection spreads from distant foci with blood or lymph flow. This can be observed in peritonitis or osteomyelitis, rye and sepsis, diphtheria and tonsillitis, periodontal disease and odontogenic phlegmon, peritonsillar or soft tissue abscess. In some cases, microbial infection joins against the background of a drop in immunity due to viral pathologies (chicken pox, influenza, measles, etc.): coccal purulent pericarditis develops. [3], [4]

The development of purulent process can act as a complication of pericardial puncture, cardiac and thoracic surgical manipulations, mechanical trauma of the heart. There are known cases of microbial inflammation caused by the presence of aortic aneurysm, malignant esophageal tumor, fungal diseases. [5]

Infectious pathogens that provoke most cases of purulent pericarditis:

• coccal flora, gram (-) microorganisms (Proteus, Pseudomonads, Klebsiella, Escherichia coli);
• Neisseria meningitidis (in patients with meningitis);
• fungal flora and protozoa (much less common than bacteria).

The causative agents of purulent pericarditis are particularly rare:

• microbial pathogens (legionellae, actinobacilli, hemophilus influenzae, histoplasmosis and tularemia pathogens);
• non-microbial pathogens of blastomycosis, amoebiasis, aspergillosis, nocardiosis, coccidiosis, candidiasis, toxoplasmosis.

Risk factors

Purulent pericarditis is a rare disease that mostly affects people who have previously suffered from pericardial pathologies, or have weakened immunity - for example, after undergoing chemotherapy courses.

Additional risk factors may include:

• a history of coronary interventions;
• hemodialysis;
• severe suppression of immune defenses;
• chronic alcoholism, drug addiction, severe stress;
• self-medicating with antibiotics;
• chest trauma, pulmonologic diseases.

Previously, before the introduction of antibiotic therapy in medicine, purulent pericarditis often complicated such diseases as pneumonia, endocarditis, meningitis and other infectious-inflammatory pathologies, including osteomyelitis, dermatitis and otitis media.

It is important to realize that factors alone do not cause purulent pericarditis, but contribute significantly to it. It is important to be aware of these factors, as many of them lead to the development of adverse effects that are both health and life threatening to the patient.

The severity of pericarditis, its symptoms and final outcome depend on the general state of health, the state of immune defense, and the peculiarities of physiology of a particular person. People leading a healthy lifestyle, eating right, observing hygienic norms are much less likely to encounter such a problem as purulent pericarditis.

It is no secret that frequent stress, alcohol and drug use, improper nutrition and the presence of chronic diseases maximally weaken human immunity, prevent the body from sufficiently resisting the introduction of infection. Alcohol and drugs disrupt the normal operation of the nervous system, reduce its activity, block the flow of basic life processes. As a result, internal organs are damaged, intoxication increases, and the body loses its ability to defend itself.

Another common point is the uncontrolled, unjustified and incorrect use of antibiotics, causing "habituation" of pathogenic microorganisms and destruction of beneficial flora. As a result of self-treatment with antibacterial drugs, the immune system loses the ability to independently and effectively fight the infectious invasion, and the risks of developing purulent processes in the body increase several times.

To prevent the occurrence of pathology, it is necessary to carefully observe the rules and norms of personal and general hygiene, refuse bad habits, avoid stressful situations and injuries, timely treat any infectious and inflammatory processes in the body, do not self-medicate.

Common risk factors to look out for:

• high cholesterol and triglyceride levels in the blood;
• high blood pressure;
• smoking;
• low physical activity;
• overweight;
• diabetes.

Additional risk is always present in people with coronary heart disease, especially against the background of smoking, atherosclerosis, hypertension, hypodynamia, obesity, sharply or permanently weakened immunity. [6]

Pathogenesis

The development of purulent pericarditis is caused by the entry of an infectious agent into the pericardial space. Infection activates the processes of production of purulent exudate - effusion into the bursa of the pericardium. Pathology is more often secondary - that is, it develops due to other infectious processes in the body. Primary disease is very rare.

Specialists indicate the presence of five main pathogenetic mechanisms of purulent pericarditis:

1. Infectious pathogens spread from nearby areas - for example, localized within the chest.
2. The infection spreads hematogenously - with the bloodstream gets to the pericardium.
3. Infection infiltrates from the heart muscle - for example, myocarditis can lead to the development of purulent pericarditis.
4. Surgical interventions on the heart and vessels, penetrating trauma (wounds) contribute to the entry of infectious agents directly into the pericardium or nearby structures.
5. Infection from the diaphragm travels to the subdiaphragm and pericardium.

The spread of pneumococcal flora usually occurs from the respiratory organs, but Staphylococcus aureus more often migrates via the hematogenous route.

Pathomorphology in purulent pericarditis includes fibrinous, serous, and purulent-inflammatory stages. Moderate effusion does not interfere with the suction capacity of the pericardial sheets, so at this stage only reddening, edema and desquamation of the mesothelium, as well as fibrin deposition between the pericardial sheets are noted. Between the epicardium and the pericardium, the presence of fibrin strands creates the effect of a so-called "hairy" heart.

Intense effusion processes in the pericardial bursa are first accompanied by an accumulation of exudate, in which there are fibrinous fibers, exfoliated mesothelium and blood cells. With the entry of infection into the pericardial bursa, the exudate becomes purulent: pathogens, protozoa, fungal infection, etc. Appear in the composition.

At the stage of pus formation and further scarring, calcification and ossification of scars may occur, which significantly impairs cardiac function. Scarring processes may spread not only to the layers of epicardium and pericardium, but also involve the endocardium. The strength and amplitude of heart contractions suffer, and the interventricular septum takes the main load: constrictive pericarditis develops. [7]

Symptoms of the purulent pericarditis

Purulent pericarditis begins acutely, with fever and chills, shortness of breath. The disease is often preceded by tonsillitis, inflammation of the lungs, as well as destructive changes in the lungs, sepsis and so on. Often there are heart pains, pericardial murmurs are heard. Quite quickly develop complications (it is important not to miss them): purulent mediastinitis, pleural empyema. Accession of complications dramatically increases the likelihood of death, even with antibiotic therapy. The cause of death of the patient often becomes:

• cardiac tamponade;
• constrictive changes;
• intoxication of the body.

If the underlying disease (root cause) has been treated with antibiotics, purulent pericarditis may begin in a blurry, erased manner, making it much more difficult to detect.

The main sign of pericarditis in general is severe intrathoracic pain and coughing. The picture is not specific, so it is necessary to pay attention to other possible symptoms - for example, the patient becomes somewhat easier if he tilts his torso forward. Additionally, there may be present:

• shortness of breath, including at rest;
• sensation of discomfort in the left limb, shoulder, shoulder blade, neck;
• Increased pain syndrome with deep inhalation or exhalation.

As the purulent inflammatory process develops, fever increases. Important: fever on the background of another, concomitant infectious process, can distract attention and mask purulent pericarditis. Therefore, the diagnosis should be approached as carefully as possible.

The basic clinical appearances are considered to be as follows:

• increasing fever;
• labored breathing;
• intrathoracic pain with possible "recoil" to the left side of the trunk (mainly to the left upper extremity or scapula);
• pulse paradoxicality;
• enlarged liver;
• increased central venous pressure;
• increasing fluid buildup in the abdominal cavity;
• auscultation: pericardial friction murmurs.

An overwhelming number of patients report fever and febrile state, and many have difficulty breathing. Chest pain is present in about one in two patients, and paradoxical pulse and increased central venous pressure are found in three to four out of ten patients.

The clinical symptomatology may be complemented by a picture of concomitant infectious pathologies, in particular:

• pneumonia (especially pneumococcal pneumonia);
• middle otitis media;
• dermatologic infections;
• meningitis (predominantly meningococcal);
• osteomyelitis (staphylococcal);
• subdiaphragm abscesses.

First signs

Purulent pericarditis most often has an acute, severe course, which is accompanied by marked intoxication, severe fever, signs of impending cardiac tamponade in acute or subacute form.

Purulent variant of the pathology often occurs as a consequence of cardiac trauma, with exudative pus accumulating in the pericardial bursa. In such a situation, the patient can survive only thanks to timely diagnosis and surgical intervention. The more rapidly purulent inflammation develops, the worse the prognosis for the patient.

The acute form of pathology begins with a rise in temperature and the appearance of aching pain in the region of the top of the heart or the lower third of the sternum. Sometimes such pain is sharp, reminiscent of myocardial infarction or pleurisy. Irradiation to the left limb, shoulder or neck, as well as to the epigastrium area is possible.

In some patients, the pain is not very pronounced, but manifests itself in the form of severe discomfort, a feeling of heaviness and pressure in the chest. Breathing becomes very difficult when walking or standing. Some relief of shortness of breath comes if the patient sits down and bends slightly to the front.

As the pus presses on the upper respiratory system, there is a dry cough due to irritation of the diaphragmatic nerve. Reflex vomiting occurs in some patients.

With increasing volume of purulent exudate accumulating in the pericardial bursa, cardiac tamponade develops. The complication is accompanied by an improper blood supply of the left ventricle and, as a consequence, insufficiency of the great circle of circulation. The problem manifests itself with the development of edema, swelling of the neck veins, fluid accumulation in the abdominal cavity, liver enlargement.

At the same time or shortly before, the temperature starts to rise. At first it is subfebrile - about 37.5°C, then fever develops. The pulse is paradoxical (decreased on inhalation), blood pressure decreases.

Signs characteristic of most patients with purulent pericarditis:

• Hectic fever with terrific chills;
• severe weakness, sudden loss of energy;
• profuse sweating;
• loss of appetite.

With cardiac dysfunction appears blueing of the extremities, shortness of breath, palpitations, heaviness and heart pain. The picture often resembles an angina attack.

Compression of nearby structures is accompanied by swelling of the cervical venous vessels, coughing, swallowing disorders.

The examination reveals a widened area of cardiac bluntness on all sides, enlargement of the vascular bundle in the II intercostal space, changes in the configuration of the heart.

On auscultation, heart tones are muffled, "gallop" rhythm and arrhythmias are possible, bronchophony and bronchial respiratory tones are noted.

Percussion reveals a blunted sound, which decreases if the patient leans forward.

If timely care is not provided, purulent pericarditis is transformed into a fibrotic or adhesive variant, which requires pericardectomy. [8]

Stages

In modern medical classification, pericarditis progresses through the following stages:

• fibrotic stage (exudate accumulates in a relatively small amount, fibrin deposition is noticeable between the pericardial sheets, and the suction capacity of the pericardium is preserved);
• serous stage (exudate accumulates more intensely, contains mesothelial elements, blood cells and fibrin flakes);
• purulent stage (in the exudate there are infectious agents, there may be processes of calcification, scarring, which limits cardiac contractile function).

The inflammatory process starts from the visceral part near the base of the organ. A small amount of exudate is absorbed into the circulatory system, fibrin deposition begins on the pericardial sheets. Gradually, the inflammatory reaction captures the entire pericardium, the back absorption of fluid is difficult. Exudate begins to accumulate. Infection joins, which is accompanied by fever and signs of intoxication of the body. [9]

Forms

• The effusive, fluid, exudative type of pericarditis.

During the inflammatory process, there is an accumulation of exudative secretions in the pericardial cavity. If the norm is considered from 15 to 50 ml of this fluid, then with pathology this volume increases to 0.5 liters and more. As a result - the fluid puts pressure on the structures of the heart, its function deteriorates, there are difficulties with breathing, pain behind the sternum, heart rate increases, blood pressure decreases. The probability of death increases.

• Acute pericarditis.

Acute variant of pathology occurs due to an infectious process, including sepsis, rheumatism, tuberculosis. The inflammatory reaction spreads to the external and internal pericardial sheets. At first, the disease proceeds by the "dry" type, then it turns into exudative pericarditis.

• Chronic form.

In the absence of timely treatment of acute pericardial pathology, the process is transformed into a chronic one: pericardial sheets thicken, and subsequently - adhere, stick together. There is an increase in temperature, patients complain of severe intrathoracic pain.

• Constrictive form.

Constrictive variant acts as a complication of the acute form of exudative pericarditis. Pathology often occurs in patients with renal or hematologic diseases, tuberculosis, rheumatism, or after previous injuries. The problem lies in the adhesion (gluing) of the sheets of the cardiac bursa, which negatively affects the function of the vital organ. The pericardium thickens, calcium salts accumulate in it, calcification processes start: a specific "shell heart" is formed.

• Traumatic form.

Chest injuries in the heart area (blunt, penetrating, gunshot, etc.) can lead to the development of a traumatic form of inflammation. The symptoms are classic: heart pain, shortness of breath.

• Purulent form.

Often purulent pericarditis acts as a complication of cardiac surgery or post-traumatic inflammation, but in the vast majority of cases, the "culprit" is an infection - in particular, especially widespread staphylococcus aureus. Pathology is accompanied by an accumulation of exudative pus in the pericardial bursa. The patient develops signs of intoxication, fever and dyspnea appear, quite severe cardiac pain.

• Nonspecific form.

Dry-type pathologic process develops as a result of an allergic or infectious reaction and proceeds in the form of alternating relapses and remissions. During relapses, the patient has increased temperature, cardiac pain and pericardial friction murmurs.

• Fibrinous form.

Fibrinous, or dry form of pathology is more characteristic of childhood and often develops in patients suffering from rheumatism. The essence of the disease is the complete disappearance of exudate from the bursa of the heart, which significantly complicates its work. The problem is accompanied by severe stabbing and aching pain, difficulty breathing.

By the nature of exudative effusion pericardial inflammation can be serous, fibrinous, purulent and mixed - for example, purulent-fibrinous or serous-purulent.

Purulent-fibrotic pericarditis is manifested by condensation of exudate with the formation of purulent pockets.

In turn, serous purulent pericarditis is a transient condition in which the serous exudate is gradually transformed into purulent fluid, and the clear effusion becomes more turbid: purulent inflammation develops. [10]

Complications and consequences

With timely intervention, purulent pericarditis can be successfully treated. If treatment is not delayed, purulent inflammation passes without complications and does not adversely affect the functionality of the body and quality of life.

Irreversible changes in the organ and various complications occur if the patient seeks medical help late, as well as in the presence of chronic coronary and other pathologies.

What purulent pericarditis can lead to:

• to cardiac tamponade (pericardial bursa fills with pus, the heart is squeezed to the point of complete stoppage of its activity);
• to inflammation of other layers-- endocardium, myocardium;
• to fibrotic pericardial thickening and subsequent impairment of coronary function;
• to heart failure, accompanied by intense circulatory failure affecting all organs and systems;
• to septic complications.

Cardiac tamponade develops as a result of the accumulation of large amounts of pus in the pericardial space and increased pressure in the bursa. This results in cardiac compression and circulatory collapse due to decreased cardiac output and systemic venous stasis. Tamponade develops rapidly or gradually, depending on the rate of exudate accumulation. The clinical picture of the complication varies from difficulty in breathing and the appearance of peripheral edema to the development of circulatory collapse. Early signs include palpitations, severe breathing problems, edema, increased venous pressure and bulging jugular veins, and widened borders of relative cardiac bluntness. Blood pressure may drop to a collaptoid state.

With the gradual onset of tamponade draw attention to the symptoms of right ventricular deficit, liver enlargement, ascites and pleural effusion, as well as pulse paradoxicality (marked decrease in systolic blood pressure - more than 10 mm Hg. - on inspiration). [11]

Diagnostics of the purulent pericarditis

Standard diagnosis includes examination, interview of the patient, listening and percussion. Among laboratory methods, the following are leading:

• a general blood test to determine the level of white blood cells and sedimentation;
• C-reactive protein score;
• evaluation of troponin and creatine kinase (cardiac-specific proteins and enzymes).

Blood tests demonstrate increased erythrocyte sedimentation rate and leukocytosis, leukocytic formula is shifted to the left, α-globulin, fibrinogen and haptoglobin in plasma are increased.

Instrumental diagnosis is usually represented by the following procedures:

• electrocardiography;
• echocardiography;
• review radiography of the chest organs;
• sometimes a CT or MRI scan.

Radiographs reveal such abnormalities:

• dilation of the cardiac contours;
• transformation of an acute cardiopulmonary angle into an obtuse one;
• loss of heart waistline;
• sharp decrease in the amplitude of pulsation of cardiac contours (up to complete loss against the background of preservation of large-vessel pulsation).

The electrocardiogram shows a decrease in the voltages of the QRS complex and T-tooth.

The most informative is echocardiography. The study helps to assess the nature and volume of exudate, detect calcium deposits.

The character of intrapericardial fluid is purulent, protein is present in large amounts, the level of leukocytes in the effusion exceeds 10000/mL (represented mainly by macrophages and granulocytes). The level of adenosine deaminase is not elevated.

Computed tomography and magnetic resonance imaging are used to determine the size and extent of exudative spread.

Pericardiocentesis is performed for confirmed purulent pericarditis.

If the tuberculous origin of purulent inflammation in the pericardium is suspected, the pericardial exudate is examined directly. Mycobacterium tuberculosis can be detected by smears, culture, histology. [12]

Differential diagnosis

Differential diagnosis is performed with various types of inflammatory pericardial processes, as well as with pathologies of non-inflammatory etiology (hydropericardium, hemopericardium, chylopericardium). Differentiation is performed by exclusion based on the results of general diagnostic measures.

Attention is paid to the likelihood of other cardiomegaly:

• Cardiomyopathies;
• isolated myocarditis;
• of certain congenital heart defects;
• Superior vena cava syndrome in mediastinal tumor processes;
• left-sided pleural effusion (the effusion volume changes with respiration, is detected posteriorly from the left ventricle and at the same time is absent in front of it, does not accumulate posteriorly from the left atrium);
• Cardiopathy due to hepatic cirrhosis.

Differential diagnosis is performed, taking into account symptomatic features, with the involvement of laboratory diagnostic procedures and imaging studies.

Beginning tamponade requires additional diagnosis.

If non-inflammatory exudate accumulates in the pericardial bursa, exudative pericarditis may be present. This should be taken into account when making a diagnosis and prescribing treatment. Thus, the likelihood of developing such conditions is monitored:

• Hydropericardium - accumulation of a large volume of fibrin-free pericardial exudate (so-called transudate) in the cardiac bursa. The problem can occur with severe right ventricular failure and is accompanied by peripheral edema, ascites, and pleural exudation. There is no chest pain, pericardial friction murmur, or ECG changes typical of pericarditis.
• Hemopericardium - accumulation of blood in the pericardial space, for example, in case of wounding or trauma, after cardiac surgery. The disorder requires urgent pericardiocentesis.
• Chylopericardium - occurs when the pericardial space is combined with the thoracic lymphatic duct. It can occur due to trauma, congenital defect or as a complication of mediastinal lymphangioma, hamartoma etc.

Treatment of the purulent pericarditis

Therapeutic measures for purulent pericarditis include:

• adherence to regimen and diet;
• anti-inflammatory, symptomatic and etiotropic therapy;
• reducing the volume of exudative pus with further control of its dynamics;
• individually and, if indicated, therapy for heart failure.

Bed rest is prescribed with the recommended semi-recumbent position - especially for the duration of fever, circulatory failure and pain syndrome.

Changes in nutrition assume a fractional diet with the elimination of salt and normalization of drinking.

Emergency drainage of the pericardial cavity to prevent cardiac tamponade is indicated. Antibiotics are administered parenterally for at least 14-28 days, as well as intrapericardially simultaneously with intensive detoxification, immunotropic and symptomatic therapeutic measures.

When a septic condition develops, the doses of antibacterial drugs are similar to those prescribed for meningitis.

If the fungal nature of the pathology is confirmed, pericardiectomy is performed.

Bacterial purulent pericarditis is treated with protected penicillins in combination with aminoglycosides. After determining the exact etiology of the inflammatory purulent process, etiotropic therapy is prescribed (depending on the causative agent).

The duration of antibiotic therapy is at least 14-28 days.

Intravenous antibiotic therapy is carried out until the febrile state is completely eliminated and the level of blood leukocytes is normalized. If the patient is in critical condition, or the introduction of penicillin drugs is impossible, then in the absence of a confirmed pathogen, vancomycin, fluoroquinolones and third-generation cephalosporins are prescribed.

Treatment with antibiotics continues under the control of the picture of bacteriologic diagnostics and examination of purulent discharge. [13]

Surgical treatment

The most common surgical procedure used for purulent pericarditis is pericardiocentesis, or pericardial puncture, which can quickly prevent and resolve cardiac tamponade and even clarify the cause of the inflammatory process.

It is impossible to perform the procedure in patients with coagulopathies, as well as those undergoing active anticoagulant therapy. A relative contraindication is a blood platelet count of less than 50x109/L.

Pericardiocentesis cannot be performed if the patient is present:

• aortic aneurysm;
• postinfarction rupture of the heart muscle;
• traumatic hemopericardium.

These cases are indications for cardiac surgery.

The cardiologist should review the results of the chest X-ray and echocardiography before proceeding with the puncture. The procedure can be performed in standard mode or under electrocardiographic control.

For adequate movement of exudative pus in the pericardial bursa, the patient should assume a half-sitting position. Additionally, blood pressure and saturation values are checked.

Instrumentation required to perform pericardiocentesis:

• intra-needle needles;
• an expanding tool;
• conductive instrument;
• curved radiopaque catheter;
• multidirectional tube adapter.

The point of pericardial puncture (if the Larrey method is used) is the apex of the angle from the rib arch on the left side to the base of the medulla. If the Marfan method is to be used, the puncture is performed at the base of the medulla on the left side.

Pericardiocentesis is a rather complex manipulation with risks of damage to coronary tissues and the coronary arterial vessel. Among the most unfavorable complications are perforation or rupture of the coronary artery or myocardium, but such problems are very rare. Other possible complications include:

• pneumothorax;
• the formation of an air embolus;
• heart rhythm disturbances;
• perforation of abdominal organs;
• pulmonary edema;
• formation of an internal mammary artery fistula.

It is important to realize that performing pericardiocentesis in patients with purulent pericarditis is a necessary measure, without which there is every risk of death.

In some cases, there is a need for pericardiectomy - surgical removal or wide resection of the parietal and visceral sheets. The procedure is indicated in patients with large volumes of purulent exudate, with frequent recurrences, resistance to drug treatment, as well as in the absence of effect from repeated pericardiocentesis.

Prevention

Prevention of purulent pericarditis consists of a set of measures of a general nature, since specific preventive measures have not been developed.

First of all, it is necessary to timely treat any infectious-inflammatory processes in the body, not waiting for the aggravation of the problem and the spread of infectious agents throughout the body.

It is recommended to exercise moderately, lead an active lifestyle, take long walks in the fresh air, swim and ride a bicycle, go on hiking trips. Almost any physical activity that brings a person pleasure and relieves nervous tension is welcome.

It is appropriate to accustom yourself to hardening procedures: an excellent restorative effect gives a contrast shower or dousing, walking barefoot on grass, water or snow, wet rubbing and wrapping.

One should not forget about adequate rest. The adequate duration of sleep for a healthy person is at least 8 hours (optimally 9 hours) per day. Some particularly active people should not neglect the opportunity to rest during the daytime.

Nutrition plays an important role in the formation of many diseases, including pericarditis. It has long been known that regular consumption of fatty, salty, spicy food negatively affects the cardiovascular system: a person develops obesity, vascular elasticity deteriorates, blood circulation is impaired, there are problems with blood pressure. In addition, a large amount of salt in the diet adversely affects the renal function, resulting in edema, and the heart experiences an unnecessary load. Regular consumption of strong tea and coffee, alcoholic beverages is also undesirable.

Specific preventive measures in the presence of infectious-inflammatory processes and immunosuppression should be discussed with the attending physician - cardiologist, internist, infectious disease specialist, rheumatologist, immunologist. Ignore preventive measures should not be ignored, because any problem is easier to prevent. In no case should you take antibiotics "for prophylaxis". Any prescription of antibiotic therapy should be carried out by a medical specialist on the basis of existing indications.

Forecast

Purulent pericarditis requires urgent medical intervention and constant monitoring of the patient. Without timely adequate treatment, there is a lethal outcome. If the pathology is recognized in time and carry out all the necessary therapeutic manipulations, then 85% of patients recover without the development of adverse long-term consequences. Intravenous antibiotic therapy should start empirically even before the moment of obtaining diagnostic bacteriologic information. Another particularly important step, in addition to antibiotic therapy, is the use of drainage. Exudative pus is draining and often accumulates rapidly. Intrapericardial thrombolysis is used to prevent exudate draining: this drug therapy is used until the final decision on surgical intervention is made. In some cases, subclavian pericardiostomy and cavitary pericardial lavage are appropriate. These procedures allow more complete drainage of pus.

Lack of competent treatment is a guarantee of lethal outcome for a patient with purulent form of the disease: the patient's death occurs as a result of increasing intoxication and the development of cardiac tamponade. With adequate and timely drug treatment, the chances of a favorable outcome increase dramatically. Complex therapy, carried out by qualified specialists in a specialized cardiology department or clinic, helps to reduce mortality to 10-15%.

Carried and even successfully treated purulent pericarditis is an indication for further registration with a specialist in cardiology or cardiac surgery.