Massive Purulent Pericardial Effusion Presenting as Atrial Fibrillation with Rapid Rate: Case Report and Review of the Literature

BACKGROUND Although pericardial effusion with afib is not rare, the combination of purulent pericardial effusion presenting as afib is not a common occurrence particularly in the developing world.The more common symptoms associated with purulent pericardial effusion are fever, dyspenia, and tachycardia. Without prompt recognition followed by antibiotics and surgical drainage, tamponade, and shock can potentially lead to death. CASE REPORT A 59-year-old male was transferred to our hospital for evaluation of afib with rapid rate associated with cough and dyspenia. He reported fevers, chills, cough and sputum for 1 week. Complaints included chest pain with relief upon lying down. Patient was afebrile with a pulse of 101 and blood pressure of 119/89. WBC 39,200 cells/ml. Chest X-RAY showed right lower lobe pneumonia and EKG revealed afib, rapid ventricular response, and secondary ST changes inferolaterally. Pericardial effusion and thickened pericardium were eveident on echo. Patient was treated for community acquired pneumonia, along with heparin and IV amiodarone. Both sputum cultures and pericardiocentesis revealed S. Pneumoniae. Cardioversion reestablished sinus mechanism. Intially pericardial effusion resolved, but later reaccumulated at which point it was decided to perform a subxiphoid pericardial window. Follow up showed no effusion and patient was asymptomatic. CONCLUSIONS Purulent pericardial effusion with atrial fibrillation and rapid ventricular rate needs to be recognized promptly. Because friction fub and chest pain are not present in every case, prompt management in the setting of pneumonia and minor hemodynamic derangements can aid in the treatment of this potentially life threating disease.