Pericardial Effusion Resulting from A Left Subphrenic Abscess, In A Paediatric Patient with Peritonitis
*Corresponding author: Dr. Jose María Gómez-Luque, Universidad de Granada, Plaza del Campillo, Granada, Spain. Tel: 678655421; Email: firstname.lastname@example.org
Complicated Intra-Abdominal Infection (IAI) is an infectious process that either affects the wall of the hollow viscera or progresses beyond its limits, reaching the peritoneal compartment. IAI is a major health problem due to its high incidence and mortality. Despite advances in surgical techniques, the provision of support measures and the availability of potent antibiotics, the mortality of IAI when septic shock develops is still around 40%. Furthermore, it usually involves a prolonged stay in the ICU and subsequently in a general ward, and requires considerable diagnostic and therapeutic resources, at great cost to the health system. The main types of IAI are peritonitis (primary, secondary and tertiary) and intra-abdominal abscesses, which can affect solid tissues or intraperitoneal organs. An intraperitoneal abscess is defined as a clearly-bounded area of purulent secretion, isolated from the rest of the peritoneal cavity by inflammatory adhesions, bowel loops and the mesentery, the greater omentum or other abdominal viscera. Among the various types of abdominal abscess, subphrenic ones are infrequent and sometimes unnoticed. Nevertheless, their mortality ranges from 11 to 31%, and so diagnosis is of vital importance for appropriate treatment to be provided. Percutaneous drainage guided by ultrasound or CT is currently the treatment of choice, together with empirical antibiotic therapy .
Tertiary peritonitis occurs in postoperative patients who do not respond to apparently adequate treatment for secondary peritonitis. From the surgical standpoint, therefore, they are persistent intra-abdominal infections with no clearly-defined focus. Pathogens are typically nosocomial, and the main types encountered are gram-positive resistant cocci (coagulase-negative Staphylococcus and Enterococcus spp, gram-negative non-fermenting bacilli and Candida sp) .
We describe the case of an 11-year-old boy, with height in the 40th percentile and weight in the 90th percentile for age. This patient was admitted to the paediatric intensive care unit (PICU) for peritonitis secondary to complicated appendicitis. In the PICU, he developed persistent fever, despite empirical antibiotic therapy with piperacillin-tazobactam and fluconazole. Examination revealed purulent abdominal accumulation of Candida albicans, the only germ isolated in all the cultures obtained. Preoperative reintervention was required, due to the persistence of fever and a worsening clinical condition, with evidence of abundant purulent material, shown by thoracic/abdominal CT scan with contrast to be inaccessible to percutaneous drainage. At 72 hours after the second intervention, the fever persisted, together with the clinical worsening. Clinical analysis produced the following results. Haemogram test: haemoglobin 9.5 g/dl; haematocrit 28.5%; platelets 362,000/μl; leukocytes 12,300/μl with 76% neutrophils, 15% lymphocytes and 6.8% monocytes. Blood biochemistry: CRP 375 mg/l; GPT, GOT, renal function and coagulation, all normal. Blood culture, urine culture, tracheal aspirate and conservative study of the central catheter were all negative. Purulent peritoneal fluid: continuing growth of Candida albicans. Physical examination revealed a poor general condition, with tachycardia and polypnea, which was alleviated by non-invasive ventilation. Pericardial friction, absent in previous examinations, was also observed. Transthoracic ultrasound examination detected significant pericardial effusion that did not, however, provoke the filling of the right cavities. A further abdominal/thoracic CT scan (Figure 1) confirmed the presence of pericardial effusion (1.5 cm) together with ipsilateral pleural effusion and left subphrenic accumulation with gas, possibly caused by a subphrenic abscess not accessible by percutaneous puncture, which had not been observed in previous examinations. Diagnostic thoracocentesis obtained pleural fluid compatible with transudate. Fluconazole treatment was replaced by micafungin, but with no improvement. Accordingly, a further intervention was performed to completely drain the left subphrenic abscess.
Fig. 1: Thoracic-abdominal CT scan with contrast showing pericardial effusion (black arrow) and a left subphrenic abscess containing air (white arrow)
At 48 hours after the second intervention, a clinical improvement had been achieved, as shown in the following analyses. Haemogram: haemoglobin, 11 g/dl; haematocrit, 32.5%; platelets, 500,000/μl; leukocytes, 14,300/μl with 76% neutrophils, 13% lymphocytes and 9.8% monocytes; CRP 120 mg / l. Blood biochemistry: GPT, GOT, renal function and coagulation study, all normal. The fever remitted, allowing the progressive withdrawal of empirical antibiotic therapy and the resolution of associated pericardial effusion without the need for pericardiocentesis. Haemodynamic and respiratory parameters returned to normal values.
The appearance of non-infectious pericardial effusion secondary to a subphrenic abscess, in a patient with peritonitis, is a complication that is rarely reported but very indicative of this pathology. Sub-diaphragmatic inflammation may affect the permeability of the junctions between the mesothelial cells of the pericardium. However, the pathophysiological mechanism by which this occurs remains unknown [2-3].
In this case, the appearance of pericardial effusion associated with clinical-analytical worsening led us to suspect the presence of a left sub-diaphragmatic intra-abdominal accumulation. This was confirmed by CT scans and was completely resolved by drainage of the fluid. It is important to note that the presence of a non-infectious pericardial effusion may be related to a left sub-diaphragmatic infection in patients subjected to surgical intervention for complicated acute appendicitis and whose subsequent recovery is unsatisfactory. This rare complication can provoke high mortality if not correctly diagnosed and treated.
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