Purulent pericarditis caused by Streptococcus pyogenes: a case report and review.

Background: Purulent pericarditis is rare and associated with significant mortality. We outline a case of Group A streptococcus (GAS, Streptococcus pyogenes) native aortic valve infective endocarditis with associated purulent pericarditis and review the literature. Of the reported cases, most occur in children and have high degrees of mortality. There are no cases that describe GAS purulent pericarditis as a complication of infective endocarditis.

Case summary: A 43-year-old female presented with an altered conscious state and refractory hypotension. An urgent transthoracic echocardiogram revealed a vegetation on the aortic valve, moderate-severe aortic regurgitation and a moderate-large circumferential pericardial effusion with evidence of early cardiac tamponade. An urgent pericardiocentesis was performed and drained 500 mL of purulent pericardial fluid. Peripheral blood and pericardial fluid cultures grew GAS. Unfortunately the pericardiocentesis did not improve the patient's haemodynamics, she developed recurrent malignant arrhythmias culminating in cardiac arrest and was unable to be resuscitated.

Discussion: To our knowledge this is the first described case of GAS purulent pericarditis arising from infective endocarditis. This case contributes to the limited evidence regarding GAS-related purulent pericarditis. Management includes multidisciplinary care with timely administration of broad-spectrum antibiotics, prompt drainage, and contemplation of early surgical intervention. Our review of the 20 reported cases of GAS purulent pericarditis reveals that only 6 out of 20 patients were over 18 years old and the mortality ranged from 40% to 85%. A high degree of clinical suspicion is required as more than half of the cases are diagnosed at post-mortem.