Management of persistent purulent pericarditis using streptokinase for intrapericardial fibrinolysis

Purulent pericarditis (PP) is a very serious condition with almost 100% mortality if untreated. Intrapericardial fibrinolysis is a preferred alternative to pericardectomy in the treatment of persistent PP, but there are no consensus guidelines on the standard protocol for this procedure in children. A 9-year-old boy was referred to the Medical Research Council Unit in The Gambia (MRC). He had been unwell for 18 days with a high continuous fever, cough, fast breathing, and dyspnoea on exertion. Prior to referral he had been treated for malaria and pneumonia with no improvement. At the MRC, he was diagnosed with purulent pericarditis caused by Staphylococcus aureus and after admission he was managed for 4 weeks with intravenous antibiotics, pericardial aspirations followed by saline lavage of the pericardium and intrapericardial antibiotic instillation. Despite these measures, massive re-accumulation of the purulent pericardial effusion continued. Once daily intrapericardial instillation of streptokinase at a dose of 18,000 i.u/kg diluted in 50 ml of normal saline, and saline washout of the pericardium after 2 hours was commenced on the 29th day of admission, in addition to the antibiotics. This technique of fibrinolysis employed for 2 days was effective in managing the persistent purulent pericarditis when pericardial aspiration and intravenous and intrapericardial antibiotics failed.