|Year : 2008 | Volume
| Issue : 1 | Page : 85-87
Pyopericardium due to group D streptococcus
K Karthikeyan1, KR Rajesh1, H Poornima1, R Bharathidasan2, KN Brahmadathan3, R Indra Priyadharsini1
1 Department of Microbiology, Vinayaka Mission Medical College, Salem - 636 308, India
2 Department of Cardiology, Vinayaka Mission Medical College, Salem - 636 308, Tamilnadu, India
3 Department of Microbiology, Christian Medical College, Vellore - 632 004, Tamilnadu, India
|Date of Submission||25-Jun-2007|
|Date of Acceptance||21-Aug-2007|
Department of Microbiology, Vinayaka Mission Medical College, Salem - 636 308
Source of Support: None, Conflict of Interest: None
Beta-hemolytic Enterococcus faecalis was isolated from the pericardial fluid obtained from a patient with pyopericardium. The patient was immunocompetent and had mild pleural effusion. He was treated with parenteral co-amoxiclav and amikacin, had undewent pericardiectomy with repeated pericardial aspiration, and recovered completely. To our knowledge, this is the first report of pyopericardium due to E. faecalis .
Keywords: Enterococcus faecalis, pleural effusion, pyopericardium
|How to cite this article:|
Karthikeyan K, Rajesh K R, Poornima H, Bharathidasan R, Brahmadathan K N, Priyadharsini R I. Pyopericardium due to group D streptococcus. Indian J Med Microbiol 2008;26:85-7
|How to cite this URL:|
Karthikeyan K, Rajesh K R, Poornima H, Bharathidasan R, Brahmadathan K N, Priyadharsini R I. Pyopericardium due to group D streptococcus. Indian J Med Microbiol [serial online] 2008 [cited 2020 Aug 9];26:85-7. Available from: http://www.ijmm.org/text.asp?2008/26/1/85/38870
In the antibiotic era, purulent pericarditis, an infection associated with high mortality, is uncommon. Several bacterial agents have been reported to cause purulent pericarditis. These include Staphylococcus , Streptococcus , Haemophilus influenzae, Pseudomonas spp., Salmonella More Details spp., Nocardia spp., coliforms and anaerobic bacteria. Bacterial pericarditis is usually characterized by purulent pericardial effusion (pyopericardium). Direct extension from pneumonia or empyema accounts for a majority of the cases. Haematogenous spread during bacteraemia and contagious spread after thoracic surgery or trauma are also important mechanisms.  Pyopericardium can also result from the rupture of perivalvular abscesses into the pericardial space in patients with endocarditis. Rarely, pericardial invasion spreads along fascial planes from the oral cavity, particularly periodontal and peritonsillar abscesses. There is increasing evidence of anaerobic organisms being grown from pericardial fluid. The pericardium can become infected during meningococcal sepsis producing primary meningococcal pericarditis. ,,
To the best of our knowledge, the present report is the first case of pyopericardium due to E. faecalis . 
| ~ Case Report|| |
A 60-year-old patient was admitted to the Cardiology Department, Vinayaka Mission Medical College Hospital, Salem, with complaints of breathlessness and mild retrosternal chest pain. On examination, the patient had engorged neck veins, muffled heart sound and presence of left basal crepts and rhonchi. Haemogram showed a total WBC count of 14,200 cells/cu mm with neutrophils 80%, lymphocytes 16% and eosinophils 4%. Haemoglobin was 11.2 gm/dL, and random blood sugar was 114 mg/dL. The other biochemical parameters including liver function tests and the serological tests like HIV and HBsAg were normal.
Echocardiography showed pyopericardium and pleural effusion. CT scan of the chest showed exudative pericardial effusion with thickened pericardium and mild bilateral pleural effusion. He was taken up for pericardiectomy and drainage and had undergone repeated pericardial aspiration using pigtail catheter, which was left in situ .
The purulent pericardial fluid was processed microbiologically. Gram stain of the direct sample showed plenty of gram-positive cocci in pairs, short chains and polymorphonuclear leucocytes. The ZN stain was negative for acid fast bacilli. The fluid culture yielded heavy growth of β -haemolytic colonies on sheep blood agar [Figure - 1] after 48 hours of incubation in candle jar and tiny lactose-fermenting colonies on MacConkey agar. The organism was catalase and oxidase negative, resistant to bacitracin, and failed to ferment mannitol. It was also positive to heat test and sodium chloride tolerance. The organism was tentatively identified as Enterococcus spp., which was resistant to penicillin but susceptible to co-amoxiclav, amikacin, linezolid and vancomycin. The strain was confirmed as E. faecalis at the Department of Microbiology, Christian Medical College, Vellore, by tests standardized in the laboratory.  Blood culture was found to be negative.
| ~ Discussion|| |
E. faecalis is an organism of the normal commensal flora of the gastrointestinal and female genitourinary tracts. Endogenous strains gain access to the sterile sites either directly or by contaminated medical equipment, resulting in nosocomial spread and colonization with multidrug-resistant strains. Once colonized, the compromised patients are at risk of developing infections with resistant strains. Most infections are nosocomial in nature and include urinary tract infections, bacteremia, endocarditis, mixed infections of abdomen and pelvis, wounds and occasionally ocular infections. 
Life-threatening infections like pyopericardium are thought to occur due to complex interplay between the magnitude of virulence of the strain and the host response. E. faecalis has virulence factors like adhesins, cytolysins and other metabolic capabilities, which may allow the organism to proliferate extensively. In addition to the above mechanisms, the infection may also be due to the multidrug resistance of the organism. ,
Pericarditis is usually secondary to the extension of an underlying condition such as infection from the pleural cavity. , For this patient, the infection would have spread from the pleural effusion that already existed. 
As this organism was resistant to penicillin, there was a possibility of developing resistance to other antibiotics also. Hence, a combination therapy (co-amoxiclav and amikacin) was administered to the patient. We have also administered anti-tuberculous drugs empirically although acid-fast staining was negative and the culture reports were awaited.
To the best of our knowledge, this is the first case of pyopericardium due to E. faecalis . Combined antibiotic therapy and daily drainage from pericardium after several days of pericardiectomy was done, which helped the recovery of the patient. The rarity of E. faecalis and its ability to develop antibiotic resistance makes the identification of the isolate and determination of its antibiotic susceptibility pattern essential for instituting proper therapy.
| ~ Acknowledgement|| |
We are grateful to Dr. K. N. Brahmadathan, CMC Vellore, for his help in identification of species and confirmation of the isolate. We are also thankful to Ms. H Poornima VMMC Salem, for her technical assistance.
| ~ References|| |
|1.||Thιbaud B, Sidi D, Kachaner J. Purulent pericarditis in children: A 15 year-experience. Arch Pediatr 1996;3:1084-90. |
|2.||Lewinter MM, Kettene S. Pericardial disease, Chapter 64. In: Braunwald's Heart Diseases: A text book of cardiovascular medicine, 7 th ed. Zipes, Libby, Bonow, Braunwalds, editors. Gopsons Papers Ltd.: Noida, India; 2005. p. 1774. |
|3.||Brook I. Pericarditis due to anaerobic bacteria. Cardiology 2002;97:55-8. |
|4.||Ku CS, Hsiung MC, Hsu TL, Ding YA, Shieh SM. Spontaneous contrast in the pericardial sac caused by gas-forming organisms. J Am Soc Echocardiogr 1991;4:67-8. |
|5.||Myers RM, Koshi G. Manual of Diagnostic procedures in Medical Microbiology and Immunology / Serology (All India Press, Pondicherry) 1982. p. 53-55, 61. |
|6.||Forbes BA, Sahm DF, Weissfeld AS, editors. Streptococcus, Enterococcus and similar organisms, Chapter 53. In: Bailey and Scott's Diagnostic Microbiology, 10 th ed. The Mosby Company: St. Louis; 1998. p. 620-35. |
|7.||Halverson KC, Van Etta LL, Langager JH. Group G streptococcal purulent pericarditis: A case report. Minn Med 1991;74:27-9. |
|8.||Snyder RW, Braun TI. Purulent pericarditis with tamponade in a postpartum patient due to group F streptococcus. Chest 1999;115:1746-7. |
|9.||Sarin S, Nee M, Kross K, Mirza MA. Enterococcus fecalis: An unusual cause of thoracic empyema. Hosp Physician 2005;49:49-51. |
|10.||Behnia M, Clay AS, Hart CM. Enterococcus faecalis causing empyema in a patient with liver disease. South Med J 2002;95:1201-3. |
[Figure - 1]