The authors report the observation of a 52-year-old Malian patient living in Sikasso (Mali), hospitalized urgently for febrile condition with arterial hypotension. The diagnosis of tamponade is made by echocardiography. Drainage of the pericardial effusion quickly improves the hemodynamic status and reveals purulent fluid. Microbiological analysis of the liquid identifies 2 different, associated pathogenic bacteria: Escherichia coli and Klebsiella pneumoniæ. Treatment with Imipenem (2 g/day by venous infusion) for 21 days leads to healing. Thirty-six months later the patient is in a stable state of clinical recovery. The authors did not find in the literature any purulent pericarditis with the 2 bacteria identified here, associated.

Purulent pericarditis, apart from tuberculosis, is rare [1]. The observation reported is a purulent pericarditis where 2 associated pathogenic bacteria were isolated, an association not previously described.

Clinical history.  A 52-year-old black Malian man living in Sikasso was hospitalized in January 2021 for febrile chest pain with dry cough and edema of the lower limbs. The clinical examination data are:

Height = 1.86 m Weight = 65 kg

Respiratory rate =22 cycles/min

Chest distensionBilateral crackling rattles

Unperceived peak shock

Low blood pressure: right arm = 90/50 mmHg                                   

                                        left arm = 80/50 mmHg

Hepatomegaly with jugular turgor

Hepatojugular reflux

Peripheral pulses weakly felt                                                       

 ECG: sinus rhythm at 98/min, diffuse repolarization disorders such as “Holzmann stage 1 pericarditis”.

Frontal chest x-ray: very enlarged cardiac shadow (cardiothoracic ratio = 0.8), basal opacity of the left lung field, barely visible recess of pleura (pleural effusion?)  (Figure 1).

Figure 1 : Frontal chest radiograph. Cardiothoracic ratio = 0.8.

Echocardiography: demonstration of a large pericardial effusion with a “swinging heart” appearance. Left and right systolic functions are preserved but the diastole of the right ventricle is of low amplitude, a sign of tamponade (figure 2).

Figure 2 : Ultrasound before puncture (apical section of the 4 cavities): large pericardial effusion and significant variations in flow, signs of poor tolerance (tamponade).

Biological results: anemia with hemoglobin at 10 g/dL and hematocrit at 35.5%, red blood cells = 4.42 million/mm3, leukocytosis at 26,400/mm3 with 82% neutrophils, platelets = 245,000/mm3C reactive protein = 50 mg/L Fasting blood sugar = 1 g/L Creatinine = 18 mg/LThe pericardial puncture brings back a brown, cloudy fluid with a purulent appearance. On direct examination under the microscope, the number of leukocytes per field is greater than 500, with 90% neutrophils and 10% lymphocytes. The culture makes it possible to isolate 2 pathogenic bacteria, Escherichia coli and Klebsiella pneumoniae and to establish an antibiogram. Both bacteria are sensitive to several antibiotics: Imipeneme, Kanamycin, Amikacin, etc.Treatment and evolution. The diagnosis of purulent pericarditis complicated by tamponade was made. High-flow oxygen therapy is installed and an ultrasound-guided pericardial puncture is performed. An hour later, a new ultrasound examination reveals the virtual disappearance of the effusion (figure 3) and signs of tamponade. Antibiotic treatment with Imipeneme is undertaken at a dose of 2 g/day, intravenously, for 21 days, under monitoring of renal function. At the end of this treatment, the clinical, biological and ultrasound assessments confirm healing. After several months (up to 36 months), the patient's condition is stable, without relapse.

Figure 3: Ultrasound after puncture (apical section of the 4 cavities):  small pericardial effusion coinciding with a spectacular clinical improvement

Purulent pericarditis is a serious, life-threatening infection [1]. Having become rare in Europe (< 1 href="%">percentage of causes of pericarditis) [2]. When the diagnosis is considered during a tamponade, it is a vital emergency [3]. The contribution of echocardiography to making the diagnosis of pericardial effusion with tamponade is then decisive [3]. As for the pathogens responsible, several have been reported but are rare apart from the tuberculosis bacillus [2]. Thus Klebsiella pneumoniæ is found responsible for purulent pericarditis in a patient undergoing hemodialysis [4], in a Nigerian child [5], in a 44-year-old Chinese woman infected with a lethal hyper-virulent form [6], in a Colombian [7]. The responsibility of Escherichia coli seems exceptional; we found only one observation in the medical literature [8]. As for the question of a Klebsiella pneumoniæ-Escherichia coli double infection, no case is reported in the literature accessible on the databases.

This clinical case demonstrates for the first time the possibility of a bacterial association in a purulent pericarditis.

No conflict of interest.