Purulent Pericarditis Post Nissen Fundoplication
Document Type
Conference Proceeding - Restricted Access
Publication Date
5-9-2025
Abstract
Purulent pericarditis is a severe form of pericardial infection characterized by the presence of pus in the pericardial space.[1] The incidence of purulent pericarditis has significantly declined in the antibiotics era, but the etiology has become more diverse. Purulent pericarditis may result from hematogenous spread, direct spread from an adjacent suppurative focus, and penetrating trauma. It could also complicate cardiothoracic surgical and invasive procedures including pericardiocentesis. [1] Prompt identification and treatment are essential in reducing mortality. Even with treatment, the mortality rate is 40%. In untreated patients, the mortality rate is nearly 85%. [1] Here, we describe a case of purulent pericarditis post Nissen fundoplication.
A 65-year-old woman with a past medical history significant for severe gastroesophageal reflux disease (GERD) complicated by esophagitis, and hiatal hernia. Due to refractory GERD symptoms despite lifestyle modifications and acid suppression therapy, the patient underwent Nissen fundoplication with hiatal hernia repair. At four-week follow-up, the patient was doing well, aside from mild subxiphoid discomfort. Two days after the follow up appointment, the patient presented to an outside emergency department (ED) with acute worsening of substernal chest discomfort associated with dyspnea. In the ED, patient was hypotensive, tachycardic, tachypneic, and in respiratory distress. EKG showed atrial flutter with nonspecific ST segment changes. CT imaging revealed large pericardial effusion and a 3-cm fluid collection in the liver concerning for abscess. Blood work revealed white blood cell count of 37400, hsTnT 148, AST >7000, ALT 3782, and a high anion gap metabolic acidosis.
Upon presentation, cardioversion was performed but failed to sustain normal sinus rhythm. The patient's respiratory status declined, requiring emergent intubation. Due to persistent hypotension, antibiotics and vasopressors were initiated, and emergent pericardiocentesis was performed for suspected cardiac tamponade. Milky white fluid was drained, rapidly improving heart rate and restoring normal sinus rhythm. Gram-stain revealed gram positive cocci in pairs. The patient remained in shock with increasing vasopressor requirements, prompting transfer to Corewell Health West (CHW). At CHW, a median sternotomy was performed. The pericardium was opened, purulent fluid evacuated, and the heart and pericardium were decorticated. Serous fluid was drained from the right pleura and dark, murky fluid from the left, followed by bilateral chest tube placement. Additional drains were placed in the inphradiaphragmatic and hepatic abscesses. Unfortunately, the patient died on the third day of hospital admission.
Purulent pericarditis is a rare, high-mortality disease. In patients with risk factors like immunosuppression, dialysis, or recent thoracic/ abdominal surgery, it should be ruled out early as prompt treatment is essential to reduce mortality. [1] Pericardiocentesis confirms diagnosis and relieves tamponade, though open drainage through subxiphoid pericardiectomy is preferred. Broad-spectrum antibiotics and antifungals are essential to initial treatment. Once a microbiologic diagnosis is established, therapy should be pathogen-directed. [2,3]
Recommended Citation
Boss B, Kemnic T, Kukhon F. Purulent pericarditis post Nissen fundoplication. Presented at: Research Day Corewell Health West; 2025 May 9; Grand Rapids, MI.
Comments
2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1688