Transdiaphragmatic rupture of hepatic abscess producing purulent pericarditis and pericardial tamponade.

A 44-year-old homeless male presented to the emergency department with a 6-hour history of pleuritic chest pain, shortness of breath, and generalized weakness. He had an episode of acute cholecystitis 2 years prior, for which he received a cholecystostomy tube and intravenous antibiotics at another hospital. He had been scheduled in clinic for tube removal and elective cholecystectomy, but he had not shown up for his appointment. The tube had remained in place, and he continued to manually drain the cholecystostomy bag once a day for the past 2 years. On review of systems, we noted low-grade fever with night sweats, progressive abdominal distention, and intermittent abdominal discomfort. In the emergency department, he was tachycardic and hypotensive. Marked jugular venous distension, faint heart sounds, clear lungs, and a distended diffusely tender abdomen with a protruding cholecystostomy tube were noted on examination. The ECG showed sinus tachycardia and diffuse ST segment elevation and PR segment depression consistent with acute pericarditis (Figure, A). A water-bottle cardioperi-cardial silhouette and diffuse pulmonary oligemia was noted on chest radiography (Figure, B). Intravenous fluid boluses and vasopressor infusions were started. Emergent bedside echocardiography showed a large circumferential pericar-dial effusion with numerous refractile densities in the fluid. Right ventricular diastolic collapse was noted (Figure, C and Movies I and II in the online-only Data Supplement). There was marked respiratory variation of mitral inflow velocities along with a dilated inferior vena cava, establishing the diagnosis of pericardial tamponade (Figure, D). On the subcostal views, we noted abnormal fluid collections in the liver that appeared to communicate with the pericardial space (Figure, E and Movies III and IV in the online-only Data Supplement). Contrast-enhanced computed tomography of the abdomen showed multiple large ring-enhancing cystic lesions nearly replacing the left hepatic lobe (Figure, F). One large abscess had eroded across the diaphragm into the pericardial space (Figure, G), producing a large emphysematous pericardial effusion with air and fluid components (Figure, H). A diagnosis of purulent pericarditis and pericardial tam-ponade secondary to transdiaphragmatic rupture of hepatic abscesses was made—the etiology of abscess formation was thought to be ascending infection via the cholecystostomy tube. Emergent needle pericardiocentesis yielded 1200 cc of purulent yellow fluid, which cultured positive for Klebsiella pneumonia and Candida glabrata. Broad-spectrum antibiotic therapy with vancomycin, meropenem, and micafungin was started. Surgical pericardial drainage, hepatic abscess resec-tion, and cholecystostomy tube removal followed. After a short period of clinical stability, the …