Unusual Complication of Pneumonia

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Unusual Complication of Pneumonia

  1. 1. AN UNUSUAL COMPLICATION OF PNEUMONIA <ul><li>by </li></ul><ul><li>Karthikeyan.S </li></ul><ul><li>Prof P.Vijayaraghavan’s Unit </li></ul>
  2. 2. 5/6/10 Mr.Kanagaraj , 23/M, came to the opd with c/o - fever - 7 days cough with expectoration - 5 days breathlessness - 3 days
  3. 3. <ul><li>HOPI- </li></ul><ul><li>fever – high grade,continuous , </li></ul><ul><li>associated with chills and rigors </li></ul><ul><li>cough with expectoration - sputum, </li></ul><ul><li>moderate amount </li></ul><ul><li>yellow coloured </li></ul><ul><li>not blood stained </li></ul><ul><li>not foul smelling </li></ul><ul><li>Breathlessness – at rest,grade 4,agg.by exertion, </li></ul><ul><li>not relieved by rest, </li></ul><ul><li>no PND/Orthopnea </li></ul>
  4. 4. <ul><li>chest pain – left sided,lower chest wall, </li></ul><ul><li>pricking type,agg. by inspiration </li></ul><ul><li>No c/o palpitations,syncope </li></ul><ul><li>No c/o urine output,abdominal distension/pain </li></ul><ul><li>leg swelling </li></ul><ul><li>No c/o jaundice </li></ul><ul><li>No c/o head ache,blurring of vision, </li></ul><ul><li>altered sensorium,involuntary movements </li></ul><ul><li>No c/o vomitting,diarrhea </li></ul><ul><li>No c/o joint swelling,rashes </li></ul><ul><li>No c/o loss of weight/but loss of appetite+ </li></ul>
  5. 5. <ul><li>Past History – </li></ul><ul><li>No c/o similar illness in the past </li></ul><ul><li>No h/o HT, DM,TB,ASTHMA,RHD </li></ul><ul><li>Personal History- </li></ul><ul><li>Not a smoker,alcoholic </li></ul><ul><li>Mixed diet </li></ul><ul><li>No h/o exposure to CSW </li></ul><ul><li>Contact History- </li></ul><ul><li>No history of contact with TB </li></ul>
  6. 6. General examination- Conscious, oriented, No pallor/icterus No cyanosis/clubbing No generalised lymphadenopathy moderately dehydration+ Dyspneic Febrile, Temp-101 F JVP elevated Vitals- Pulse- 120/min, regular, nomal volume B.P- 100/70 mm Hg
  7. 7. System examination: CVS – S1S2 normally heard, no murmur RS – BAE, Over left mammary,axillary,infra-axillary, lower interscapular and infra-scapular areas- Crepitations+ VF/VR Bronchial breathing-tubular Egophony+
  8. 8. ABDOMEN: soft, no organomegaly CNS: No focal neurological deficit
  9. 9. Provisional Diagnosis <ul><li>Left lower lobe Pneumonitis with </li></ul><ul><li>?Myocarditis </li></ul>
  10. 11. ECG:
  11. 12. ECG:
  12. 13. Provisional diagnosis <ul><li>PERICARDIAL EFFUSION WITH </li></ul><ul><li>?MILD/LOW PRESSURE CARDIAC TAMPONADE </li></ul>
  13. 16. ECHO: <ul><li>Dense echogenic shadow in pericardial cavity </li></ul><ul><li>Normal chambers and valves </li></ul><ul><li>? Effusive pericarditis with pyopericardium </li></ul><ul><li>SUGGESTED: Emergency pericardial window </li></ul>
  14. 17. Baseline Investigations: <ul><li>CBC : RFT : </li></ul><ul><li>Hb: 12 g B.UREA:20 mg/dl </li></ul><ul><li>TC: 13,500 Sr.Creatinine:1 mg/dl DC: P75 L24E1 Sr.Electrolytes </li></ul><ul><li>ESR: 20/40mm Na - 138 </li></ul><ul><li>Plt: 1.2 lakhs K - 4.1 </li></ul><ul><li>PCV:36% Urine analysis : </li></ul><ul><li>albumin –nil </li></ul><ul><li>sugar-nil </li></ul><ul><li> deposits- 1-2 pus cells </li></ul>
  15. 18. Contd… <ul><li>CPK-MB-no kit </li></ul><ul><li>Sputum C/S </li></ul><ul><li>Sputum AFB (sample sent) </li></ul><ul><li>Blood C/S </li></ul><ul><li>ELISA –HIV </li></ul><ul><li>Manteaux- negative </li></ul>
  16. 19. Initial treatment: <ul><li>Inj.Ceftriaxone 1g i.v b.d </li></ul><ul><li>Inj.Metronidazole 500 mg i.v t.i.d </li></ul><ul><li>Inj.Deriphylline 2cc i.v b.d </li></ul><ul><li>Inj.Ranitidine 50 mg i.v b.d </li></ul><ul><li>T.Bromhexine 1 t.i.d </li></ul><ul><li>T.Paracetomol 1 t.i.d </li></ul><ul><li>Salbutamol nebulisation 6 hrly </li></ul><ul><li>Tepid sponging </li></ul>
  17. 20. 6/6/10 <ul><li>Anaesthetic fitness obtained for emergency pericardectomy </li></ul><ul><li>Pt. transferred to CTS ward </li></ul>
  18. 21. 16/6/10 <ul><li>Pt. GC was stable, afebrile, not dyspneic </li></ul><ul><li>JVP - prominent “y” descent </li></ul><ul><li>Vitals : stable </li></ul><ul><li>CVS,ABDOMEN,CNS – NAD </li></ul><ul><li>RS: BAE, minimal crepitations+ in left lower lung </li></ul><ul><li>fields </li></ul>
  19. 22. Contd…. <ul><li>Sputum C/S – Streptococcus pneumoniae grown, </li></ul><ul><li>sensitive to cefotaxim,ceftriaxone </li></ul><ul><li>Sputum AFB –negative </li></ul><ul><li>Blood C/S – no growth </li></ul><ul><li>ELISA-HIV- negative </li></ul>
  20. 23. 17/6/10 Repeat Echo: <ul><li>Pericardial effusion 14 mm + </li></ul><ul><li>Moderately dense strands + in posterior aspect </li></ul><ul><li>Septal bounce+ </li></ul><ul><li>IVC dilated </li></ul><ul><li>Minimal respiratory variation </li></ul><ul><li>Features S/O constrictive pericarditis </li></ul>
  21. 24. Final diagnosis <ul><li>LEFT LOWER LOBE PNEUMONITIS </li></ul><ul><li>EFFUSIVE PERICARDITIS </li></ul><ul><li>CONSTRICTIVE PERICARDITIS </li></ul>
  22. 25. 5/7/10 <ul><li>Pericardectomy was done(! finally) </li></ul>
  23. 28. <ul><li>Specimen </li></ul><ul><li>AFB-negative </li></ul><ul><li>c/s – No growth </li></ul><ul><li>Biopsy-report not obtained </li></ul>
  24. 30. Post op ECG:
  25. 33. <ul><li>Discussion : </li></ul><ul><li>PERICARDITIS </li></ul><ul><li>- inflammation of the pericardium ,both visceral </li></ul><ul><li>and parietal </li></ul><ul><li>CLASSIFICATION : </li></ul><ul><li>1.Clinical </li></ul><ul><li>2.Aetiological </li></ul>
  26. 34. Clinical classification <ul><li>1.acute pericarditis </li></ul><ul><li>< 6 weeks </li></ul><ul><li>a. fibrinous </li></ul><ul><li>b.effusive </li></ul><ul><li>2.subacute pericarditis </li></ul><ul><li>6 weeks – 6 months </li></ul><ul><li>a.effusive </li></ul><ul><li>b.constrictive </li></ul><ul><li>3.chronic pericarditis </li></ul><ul><li>> 6 months </li></ul><ul><li>a. constrictive b. effusive </li></ul>
  27. 35. Aetiological classification <ul><li>1. Infectious pericarditis </li></ul><ul><li>a.viral – cox A, B ,ECHO ,mumps ,HIV, hepatitis </li></ul><ul><li>b.pyogenic- pneumococcus ,staphylococcus ,neisseria </li></ul><ul><li>legionella </li></ul><ul><li>c.tuberculosis </li></ul><ul><li>d.fungal </li></ul><ul><li>e.protozoal </li></ul><ul><li>2.Non infectious: </li></ul><ul><li>a. AMI d. myxedema g. trauma </li></ul><ul><li>b. uremia e. cholesterol h.aortic dissection </li></ul><ul><li>c.neoplasia f. chylopericardium i.post irradiation </li></ul><ul><li>FAMILIAL –mulibrey nanism </li></ul>
  28. 36. <ul><li>3. Pericarditis related to hypersensitivity /autoimmunity: </li></ul><ul><li>a.rheumatic fever </li></ul><ul><li>b.collagen vascular diseases </li></ul><ul><li>c. drugs </li></ul><ul><li>- procainamide ,hydralazine </li></ul><ul><li>d.post cardiac injury </li></ul><ul><li>1) dressler </li></ul><ul><li>2) post pericardiotomy </li></ul><ul><li>3) post traumatic </li></ul>
  29. 37. Clinical picture <ul><li>Chest pain –sharp ,pleuritic ,lower left sternal border, </li></ul><ul><li>radiation to the trapezius,aggravated on lying </li></ul><ul><li>down,relieved on upright posture ; </li></ul><ul><li>others: fever ,dyspnea ,cough ,hiccough </li></ul><ul><li>Signs </li></ul><ul><li>pericardial friction rub - 85 % patients ,lower left sternal </li></ul><ul><li>border ,grating /scratching </li></ul><ul><li>- three components –ventricular </li></ul><ul><li>systole ,early diastole ,atrial </li></ul><ul><li>contraction </li></ul><ul><li>Signs that are clues to etiological diagnosis </li></ul>
  30. 38. <ul><li>Laboratory investigations : </li></ul><ul><li>ECG – changes secondary to acute subepicardial </li></ul><ul><li>inflammation </li></ul><ul><li>4 stages ;-- </li></ul><ul><li>stage 1. widespread ST segment elevation with </li></ul><ul><li>upward concavity ,PR segment depression </li></ul><ul><li>stage 2 . ST segment returning to normal </li></ul><ul><li>stage 3 . T wave inversion </li></ul><ul><li>stage 4 . ECG returning to normal </li></ul><ul><li>differential diagnosis– AMI ,ERS </li></ul>
  31. 39. <ul><li>CARDIAC ENZYMES – CPK MB and TROP I elevated-silent myo </li></ul><ul><li>carditis </li></ul><ul><li>TROP I modestly elevated without </li></ul><ul><li>CPKMB –epicardial inflammation </li></ul><ul><li>ECHO: </li></ul><ul><li>usually normal </li></ul><ul><li>silent effusion </li></ul><ul><li>ventricular dysfunction associated with myo carditis </li></ul><ul><li>OTHER INV; </li></ul><ul><li>CBC ,CHEST X RAY ,INV. TO FIND OUT SPECIFIC AETIOLOGY LIKE </li></ul><ul><li>ANA FOR SLE </li></ul>
  32. 40. MANAGEMENT <ul><li>Depends on the aetiology : </li></ul><ul><li>If the diagnosis is uncertain it is labelled as ‘ acute idiopathic </li></ul><ul><li>pericarditis ‘ treatment of which is </li></ul><ul><li>T.Brufen 600 mg tid </li></ul><ul><li>if no or inadequate response </li></ul><ul><li>T. colchicine or T.prednisolone can be given </li></ul><ul><li>if still no response / develops effusion </li></ul><ul><li>admission and diagnostic centesis and treat </li></ul><ul><li>accordingly </li></ul>
  33. 41. Viral pericarditis <ul><li>Most common infection of the pericardium ; </li></ul><ul><li>Coxsackie A,B , mumps ,ECHO ,influenza ,HIV, CMV , </li></ul><ul><li>Develops 10 – 12 days after a presumed viral illness </li></ul><ul><li>Presents in association with pneumonitis & pleural effusion </li></ul><ul><li>Management ; </li></ul><ul><li>hyper immune globulin – CMV, parvovirus ,adeno virus </li></ul><ul><li>interferon alpha – coxsackie B </li></ul><ul><li>aspirin 2 – 4 mg /day </li></ul><ul><li>brufen/colchicine / prednisolone </li></ul>
  34. 42. Bacterial pericarditis <ul><li>Characterised by purulent effusion </li></ul><ul><li>Organisms – staphylococcus ,peumococcus ,streptococcus, </li></ul><ul><li>neisseria ,legionella </li></ul><ul><li>Mode of spread – </li></ul><ul><li>1. contiguous –extension from pneumonia /empyema </li></ul><ul><li>head neck /mediastinum </li></ul><ul><li>2. haematogenous </li></ul><ul><li>Clinical manifestations ;- high grade fever ,chills ,rigor </li></ul><ul><li>chest pain , dyspnea ,pericardial rub </li></ul><ul><li>Laboratory features ;- </li></ul><ul><li>CBC – leucocytosis with left shift , </li></ul><ul><li>Pericardial fluid- high protein ,low glucose ,increased </li></ul><ul><li>neutrophils ,high LDH </li></ul><ul><li>specific organism can be grown </li></ul>
  35. 43. Management <ul><li>Suspected /proven bacterial pericarditis is a medical </li></ul><ul><li>emergency </li></ul><ul><li>Closed pericardiocentesis and subsequent catheter </li></ul><ul><li>drainage for three to four days </li></ul><ul><li>Purulent pericardial effusions likely to recur ,hence </li></ul><ul><li>pericardial window necessary </li></ul><ul><li>If patient develops constrictive pericarditis – </li></ul><ul><li>pericardiectomy done </li></ul>
  36. 44. Tuberculous pericarditis <ul><li>More common in the developing world ;more in immuno compromised; </li></ul><ul><li>Clinical picture : </li></ul><ul><li>- chronic systemic illness with pericardial effusion </li></ul><ul><li>/constrictive pericarditis ; </li></ul><ul><li>-only 3 -4% present with acute/subacute pericarditis; </li></ul><ul><li>Pericardial involvement usually secondary to peribronchial </li></ul><ul><li>peritracheal or mediastinal lymphnode involvement </li></ul><ul><li>Haematogenous spread is also common </li></ul><ul><li>Contiguous spread from a necrotic focus less common </li></ul>
  37. 45. Diagnosis <ul><li>Definite diagnosis –isolating the organism from the </li></ul><ul><li>pericardial fluid or biopsy—very difficult </li></ul><ul><li>Adjuvant investigations – pericardial fluid ADA > 40 u/l </li></ul><ul><li>mantoux,IFN gamma </li></ul><ul><li>PCR to detect M.tuberculosis DNA </li></ul><ul><li>Management ;- </li></ul><ul><li>even if the definitive diagnosis is lacking but biopsy shows </li></ul><ul><li>granuloma, anti tuberculous drugs can be started </li></ul><ul><li>Corticosteroids -role inconclusive </li></ul>
  38. 46. Constrictive pericarditis <ul><li>Its an end stage of inflammatory process involving the </li></ul><ul><li>pericardium </li></ul><ul><li>Causes : Idiopathic,infection ,irradiation ,postsurgical, </li></ul><ul><li>Autoimmune ,neoplastic ,uremia ,posttrauma </li></ul><ul><li>sarcoidosis ,methysergide therapy , </li></ul><ul><li>Tuberculosis is an important cause in developing countries; </li></ul><ul><li>: </li></ul>
  39. 47. <ul><li>Pathophysiology: </li></ul><ul><li>inflammation of the pericardium </li></ul><ul><li>fibrosis & calcification </li></ul><ul><li>adhesion between visceral & parietal pericardium </li></ul><ul><li>constrictive pericarditis </li></ul>
  40. 48. Hemodynamics <ul><li>restricted filling of heart </li></ul><ul><li>elevation and equilibration of </li></ul><ul><li>filling pressures in all chambers </li></ul><ul><li>ventricles fill abnormally & rapidly </li></ul><ul><li>in early diastole </li></ul><ul><li>early to middiastole ventricular filling ceases </li></ul><ul><li>due to stiff pericardium /all filling occurs </li></ul><ul><li>in early diastole </li></ul><ul><li>“ the prominent y descent” </li></ul>
  41. 49. Contd……. <ul><li>1. Failure of transmission of intrathoracic pressure to cardiac </li></ul><ul><li>chambers –vital factor in the hemodynamics of constrictive </li></ul><ul><li>pericarditis ; </li></ul><ul><li>inspiration –drop in intrathoracic pressure </li></ul><ul><li>drop in pulmonary venous pressure but not left </li></ul><ul><li>atrial pressure </li></ul><ul><li>decreased pulmonary vein to left atrial pressure </li></ul><ul><li>gradient </li></ul><ul><li>leading to dec.LV filling & inc.RV filling </li></ul><ul><li>& septal shift to left </li></ul><ul><li>“ Exaggerated respiratory variation in flow velocity” </li></ul>
  42. 50. Clinical presentation <ul><li>Initial symptoms : leg swelling ,abdominal distension, </li></ul><ul><li>anasarca </li></ul><ul><li>Later – exertional dyspnea ,cough ,orthopnea ,muscle wasting , </li></ul><ul><li>cachexia </li></ul><ul><li>Signs : </li></ul><ul><li>elevated JVP –prominent x & y descent –results in M/W </li></ul><ul><li>pattern </li></ul><ul><li>Kussmaul’s sign positive </li></ul><ul><li>Pericardial knock present </li></ul><ul><li>TR murmur + </li></ul><ul><li>hepatomegaly + </li></ul>
  43. 51. Laboratory investigations <ul><li>ECG ; nonspecific T wave changes </li></ul><ul><li>reduced voltage of QRS complex </li></ul><ul><li>atrial fibrillation </li></ul><ul><li>Chest x ray ; cardiac silhoutte enlarged </li></ul><ul><li>pericardial calcification </li></ul><ul><li>pleural effusion </li></ul><ul><li>Prominent pulmonary vasculature </li></ul><ul><li>ECHO ; pericardial thickening ,abrupt displacement of the </li></ul><ul><li>IVS during early diastole ;septal bounce </li></ul><ul><li>SVC & IVC dilated ; </li></ul><ul><li>Doppler flow velocity –exaggerated respiratory variations </li></ul><ul><li>in mitral flow velocity </li></ul><ul><li>Cardiac catheterisation– square root sign </li></ul>
  44. 52. Management <ul><li>Medical management ; </li></ul><ul><li>-- diuretics ,salt restriction </li></ul><ul><li>Surgical management ; </li></ul><ul><li>--pericardiectomy is the definitive treatment </li></ul><ul><li>Prognosis </li></ul><ul><li>LV diastolic function returns to normal in 90 – 95 % of </li></ul><ul><li>cases early or late </li></ul><ul><li>poor prognosis associated with myocardial atrophy or </li></ul><ul><li>fibrosis ,incomplete resection ,mediastinal fibrosis </li></ul>
  45. 53. <ul><li>Cardiac tamponade : </li></ul><ul><li>accumulation of fluid in pericardial space </li></ul><ul><li>sufficent to cause obstruction to inflow of blood </li></ul><ul><li>cardiac tamponade </li></ul><ul><li>Quantity of fluid 200 ml -if accumulates rapidly; </li></ul><ul><li>>2000 ml –if slow accumulation; </li></ul>
  46. 54. Causes <ul><li>1.Neoplastic disease </li></ul><ul><li>2.Idiopathic pericarditis </li></ul><ul><li>3.Renal failure </li></ul><ul><li>4. Tuberculosis </li></ul><ul><li>5.Hemopericardium due to use of anticoagulants </li></ul><ul><li>6.Bleeding into the pericardial cavity following cardiac </li></ul><ul><li>surgeries </li></ul>
  47. 55. Hemodynamics <ul><li>fluid accumulation in pericardial sac </li></ul><ul><li>atrial & ventricular diastolic pressure rise </li></ul><ul><li>equalise at a pressure similar to that of </li></ul><ul><li>pericardial sac -15 – 20 mmhg </li></ul><ul><li>small end diastolic ventricular volume /stroke volume </li></ul><ul><li>hypotension </li></ul>
  48. 56. <ul><li>The mean initial right atrial pressure is lower than the left </li></ul><ul><li>atrial pressure and hence as the fluid accumulates right </li></ul><ul><li>sided diastolic collapse occurs; </li></ul><ul><li>The total heart volume is fixed in cardiac tamponade ; </li></ul><ul><li>The loss of y descent and the presence of x descent can be </li></ul><ul><li>explained by the above concept </li></ul>
  49. 57. <ul><li>y descent occurs usually when tricuspid valve </li></ul><ul><li>opens </li></ul><ul><li>blood is not leaving the heart </li></ul><ul><li>no blood can enter the heart </li></ul><ul><li>loss of y descent </li></ul>
  50. 58. <ul><li>x descent occurs during ventricular ejection </li></ul><ul><li>blood leaves the heart </li></ul><ul><li>venous inflow present </li></ul><ul><li>x descent retained </li></ul>
  51. 59. Pulsus paradoxus <ul><li>During inspiration </li></ul><ul><li>increase in rt.heart filling </li></ul><ul><li>IVS shift to left </li></ul><ul><li>decreased LV filling ( due to constancy of </li></ul><ul><li>heart volume) </li></ul><ul><li>decreased LV stroke volume </li></ul>
  52. 60. Clinical features <ul><li>Cough ,dyspnea ,orthopnea </li></ul><ul><li>Pericardial pain /discomfort </li></ul><ul><li>Signs – </li></ul><ul><li>diaphioretic ,cyanosis ,altered sensorium ,hypotension </li></ul><ul><li>tachycardia ,tachypnea </li></ul><ul><li>pulsus paradoxus , </li></ul><ul><li>BECK’s triad </li></ul>
  53. 61. Lab. Investigations <ul><li>ECG ; </li></ul><ul><li>reduced voltage and electrical alternans ( antero </li></ul><ul><li>posterior swinging of the heart ) </li></ul><ul><li>Chest x ray ;- </li></ul><ul><li>enlarged cardiac silhoutte ,flask shaped heart </li></ul><ul><li>oligaemic lung fields </li></ul><ul><li>Echo ; </li></ul><ul><li>pericardial effusions , </li></ul><ul><li>RA and RV diastolic collapse </li></ul><ul><li>exaggerated respiratory variations in mitral flow </li></ul><ul><li>velocities </li></ul>
  54. 62. Management <ul><li>It is a potential medical emergency </li></ul><ul><li>In critically ill patients emergency closed pericardiocentesis </li></ul><ul><li>is done </li></ul><ul><li>In mild effusions such as due to idipathic effusions conservative </li></ul><ul><li>management with a course of NSAIDs /colchicine used </li></ul><ul><li>In case of loculated effusion and effusion containing clots /purulent exudates an open approach with a window is advisable </li></ul>
  55. 63. Effusive constrictive pericarditis <ul><li>Combination of tense effusion and constriction of heart </li></ul><ul><li>by thickened pericardium </li></ul><ul><li>Features of effusion causing compression and constrictive pericarditis present </li></ul><ul><li>Causes ; </li></ul><ul><li>tuberculosis, scleroderma ,radiation ,neoplasm ,renal </li></ul><ul><li>failure </li></ul><ul><li>Diagnosis </li></ul><ul><li>pericardiocentesis and biopsy </li></ul><ul><li>Treatment </li></ul><ul><li>pericardiectomy </li></ul>
  56. 64. Low pressure tamponade <ul><li>Mild tamponade where intra pericardial pressure is slightly </li></ul><ul><li>elevated to 5 – 10 mmhg </li></ul><ul><li>CVP is slightly elevated </li></ul><ul><li>Arterial pressure is unaffected </li></ul><ul><li>No paradoxical pulse ;Usually associated with hypovolemia </li></ul><ul><li>Treatment ; </li></ul><ul><li>periacrdiocentesis </li></ul>
  57. 66. References <ul><li>Harrison’s principles of internal medicine </li></ul><ul><li>-17 th edition </li></ul><ul><li>Braunwald’s heart disease </li></ul><ul><li>-8 th edition </li></ul>

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