Cardiac tamponade due to group a streptococcal pericarditis in a 10-month-old boy and a review of the literature

doi:10.4236/ojped.2011.14020

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Open Journal of Pediatrics, 2011, 1, 87-89

doi:10.4236/ojped.2011.14020 Published Online December 2011 (http://www.SciRP.org/journal/ojped/ OJPed

)

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJPed

Cardiac tamponade due to group a streptococcal pericarditis

in a 10-month-old boy and a review of the literature

Matthew C. Schwartz1*, Matthew J. Gillespie1, Paul Stephens Jr.1, Brian Fisher2

1Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelph ia, USA;

2Division of Infectious Disease and Center for Clinical Epidemiology and Biostatistics, The Children’s Hospital of Philadelphia,

Philadelphia, USA.

Email: *[email protected]

Received 18 September 2011; revised 27 October 2011; accepted 8 November 2011.

ABSTRACT

Group A streptococcus (GAS) is a rare cause of pu-

rulent pericarditis in pediatric patients as only 7

cases have been reported. We present a 10-month-old

boy who developed cardiac tamponade from GAS

and was successfully treated with subxiphoid tube

drainage and 4 weeks of antibiotics at the Children’s

Hospital of Philadelphia.

Keywords: Streptococcus; Pericarditis; Pericardiocente-

sis; Tamponade

1. INTRODUCTION

Group A streptococcus (GAS) is a rare cause of bacterial

pericarditis in children with only 7 pediatric cases pre-

viously reported [1-5]. We describe a 10-month-old who

developed cardiac tamponade due to GAS pericarditis

and was successfully treated.

2. CASE REPORT

A 10-month-old boy presented to the Children’s Hospital

of Philadelphia (CHOP) Emergency Department (ED)

with 9 days of fever accompanied by a transient papular

rash, but no other localizing symptoms. He underwent

outpatient evaluation on day 6 and was diagnosed with

roseola. The patient’s fever continued prompting his

presentation.

His birth and past medical histories were unremark-

able. He lived in Philadelphia and had no exposures or

travel. Several days into the child’s illness, his father

was diagnosed with GAS pharyngitis by rapid strepto-

coccal antigen test and was treated.

In the ED, he had a rectal temperature of 38.2˚C. The

remainder of his vital signs and physical exam were

normal except for mild bilateral anterior cervical lym-

phadenopathy. Initial laboratory testing showed a white

blood cell count of 20,500/uL (63% neutrophils, 26%

lymphocytes), a hemoglobin of 10.2 g/dL, a platelet

count of 57,400/u L, an erythrocyte sedimentation rate of

75 mm/hr, a C-reactive protein of 6.2 mg/dL, an albumin

of 3.7 g/dL, an aspartate aminotransferase of 109 U/L,

and an alanine aminotransferase <6 U/L. Urinalysis and

chest radiograph were normal. Urine and blood cultures

were sent as was a respiratory virus polymerase chain

reaction (PCR) panel on respiratory secretions.

The patient was admitted for evaluation. On hospital

day 1, the respiratory virus PCR panel returned negative

for adenovirus, respiratory syncytial virus, influenza A

and B, parainfluenza 1 - 3, metapneumovirus, and rhino-

virus. Serum was sent for adenovirus PCR, human her-

pes virus-6 (HHV6) PCR , cytomegalovi r us ( C M V) PCR,

and Ebstein Barr virus (EBV) serology. To consider oc-

cult osteomyelitis, a whole body magnetic resonance

imaging scan was obtained and was negative. In light of

possible Kawasaki Disease, an echocardiogram was

performed, revealing a small, 4 mm posterior pericardial

effusion, normal biventricular systolic function, and mild,

diffuse ectasia of the right coronary artery (proximal

right coronary artery z-score 2.62).

Due to fever, elevated inflammatory markers, an ele-

vated aspartate transferase, and ectasia of the right coro-

nary artery, incomplete Kawasaki Disease was suspected.

On hospital day 2, the patient was treated with intrave-

nous immunoglobulin and aspirin was started. From

hospital day 3 through 5, the patient’s fever continued

and his inflammatory markers increased. Serial blood

cultures remained negative and urine culture at the time

of admission was negative. The serum adenovirus PCR,

CMV PCR, and EBV serologies returned negative. The

patient’s HHV6 serum PCR returned as mildly positive

(1981 copies/mL). The Infectious Disease Service was

consulted and felt HHV6 not likely responsible for the

illness.

By hospital day 6, the patient remained febrile and

had increased work of breathing. Chest x-ray showed an

M. C. Schwartz et al. / Open Journal of Pediatrics 1 (2011) 87-89

enlarged cardiac silhouette and echocardiogram showed

a large circumferential pericardial effusion (1.2 cm) with

early signs of tamponade physiology including right

atrial collapse in late ventricular diastole (Figure 1). The

coronary arteries appeared normal with no evidence of

right coronary artery ectasia. An electrocardiogram

showed sinus tachycardia with no ST segment or PR

segment changes.

The patient was transferred to the Intensive Care Unit

and pericardiocentesis drained 65 cc of purulent fluid

and a drain left in place. The gram stain showed gram

positive cocci and empiric antibiotics were started. The

bacteria was subsequently identified as Group A beta

hemolytic streptococcus and the antibiotics changed to

intravenous penicillin G. The patient improved and the

pericardial drain was removed several days after peri-

cardiocentesis. The patient completed 14 days of intra-

venous antimicrobials following drainage and was dis-

charged home to complete another 14 days of oral peni-

cillin (total 4 week course).

Four months after discharge, the patient was well and

echocardiogram showed a normal pericardial sac.

3. DISCUSSION

Pericarditis is uncommon in children. Of 20 cases re-

ported by Roodpeyma et al., 8 (40%) were bacterial, 6

(30%) associated with collagen vascular disease, 4 (20%)

were viral, and 2 (10%) due to mass invasion of the

pericardium [6]. Pericarditis can also be related to post-

pericardiotomy syndrome or can be idiopathic.

Clinical signs of purulent pericarditis include fever,

tachycardia, tachypnea, hepatomegaly, and decreased

Figure 1. Transthoracic apical four chamber view showing a

large, circumferential pericardial effusion with fibrinous

strands and diastolic right atrial collapse consistent with tam-

ponade physiology.

cardiac sounds. Patients rarely present with pericardial

friction rub because the pericardial space is distended

with pus. Electrocardiogram often shows decreased

voltages and diffuse ST elevation and chest x-ray usually

shows an enlarged cardiac shadow. All patients will have

significant pericardial fluid by echocardiography and

many children with bacterial pericarditis will present

with cardiac tamponade [2,7].

Our patient presented in a more indolent fashion with

long-standing fever. It is possible that the illness was two

separate infections such as a viral syndro me followed by

invasive GAS. GAS invasive disease occurring in the

setting of viral infection has been described although

association of GAS infection with HHV-6 has not been

reported [8,9]. The patient had a mildly positive serum

HHV-6 PCR on day 9 of his illness which raises the pos-

sibility of an initial HHV-6 infection, but is not conclu-

sive.

Purulent pericarditis co mmonly develops seco ndary to

a primary bacterial infection at an alternate location,

most commonly pneumonia [2,7]. Septic emboli or di-

rect spread from the lungs then acts to seed the pericar-

dium. In our patient, the pericardium likely was the pri-

mary site of invasive infection.

The most common cause of bacterial pericarditis in

children is Staphylococcus aureus [6,7]. Streptococcus

pneumonia e and Haemophilus influenzae are also some-

times isolated [2,7]. GAS, however, is a rare cause. Re-

view of the literature shows that only 7 cases have ever

been reported in pediatric patients (Ta b l e 1) [1-5]. One

case was not described in detail [2], but the ages of the

other 6 cases range from 13 months to 14 years with 3

males and 3 females. Our patient is the youngest patient

reported with this entity. Three patients had an identifi-

able source of GAS infection; 1 patient had pharyngitis

and cellulitis, 1 patient pharyngitis alone, and another

patient had pneumonia. All were treated with penicillin

or a penicillin derivative except one, whose antibiotic

regimen was not described. In the 2 reports that de-

scribed the entire course of antibiotics, both patients

received four weeks of therapy [1,5]. All underwent

pericardiocentesis with isolation of GAS from pericar-

dial fluid. Two patients also underwent surgical pericar-

dial intervention. One of the 6 patients died; a 2 year old

female was diagnosed with viral pharyngitis several days

before presenting in respiratory distress and deteriorating

shortly after admission despite pericardiocentesis [3]. Of

the 5 surviving patients, none developed constrictive

pericardial disease with limited follow-up.

Systemic antibiotics and pericardial drainage are both

needed to treat of purulent pericarditis. Antibiotics must

include an antistaphylococcal agent until the organism is

identified. There are no guidelines regarding length of

M. C. Schwartz et al. / Open Journal of Pediatrics 1 (2011) 87-89

Table 1. Previously reported cases of purulent pericarditis in children due to Group A Streptococcus.

Reference Year Treated Age SexAntibiotic Source Drainage Survival

Gersony, et al. 1967*

Vigneswaran, et al. 1985. Not documented 14 yo M Penicillin G ×10 days,

then oral Penicillin

V × 4 weeks

Pharyngitis,

Cellulitis Pericardiocentesis,

Pericardial window Alive, f/u 8 weeks

Thebaud, et al. 1996. 1979 13 mo M Ampicillin,

Gentamicin No extracardiac

source Pericardiocentesis Not documented

Thebaud, et al. 1996. 1981 3 yo F Oxacillin,

Gentamicin No extracardiac

source Pericardiocentesis Not documented

Thebaud, et al. 1996. 1985 14 mo F Amoxicillin,

Neomycin Pneumonia Pericardiocentesis Not documented

Pruitt, et al. 1989. 1987 2 yo F Not

documented Pharyngitis Pericardiocentesis Died 4d after

presentation

Bhaduri-McIntosh,

et al. 2006. 2004 6 yo M Penicillin G × 4 weeksNo extracardiac

source Pericardiocentesis,

Pericardiectomy Alive, f/u 12

months

*Review does not incl ud e details of case.

antimicrobial therapy, but most patients are treated with

2 to 4 weeks of intravenous therapy [1,5,7]. Several op-

tions for pericardial drainage exist including subxiphoid

tube placement, pericardial window creation, partial

pericardiectomy, total pericardiectomy, and/or infusion

of thrombolytics into the pericardial space following

pericardiocentesis. Factors such as the consistency of the

fluid, the patient’s clinical status, and the cause of peri-

carditis influence which modality is chosen.

OJPed

Even with therapy, the mortality in bacterial pericardi-

tis in children ranges from 5% to 12% [1,6,7]. Our pa-

tient was successfully treated with antibiotics and subxi-

phoid tube drainage without evidence of pericardial con-

striction 4 months after treatment completion.

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[2] Gersony, W.M. and McCracken, G.H. (1967) Purulent

pericarditis in infancy. Pediatrics, 40, 224-232.

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previously well child. Pediatric Infectious Disease Jour-

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