Intrapericardial fibrinolysis in purulent pericarditis-case report

Purulent pericarditis (PP) continues to result in a very serious prognosis and high mortality. The most serious complication of pericarditis is constriction. Intrapericardial administration of fibrinolytic agents, although controversial, can prevent the development of constrictions. We present the case of a 63-year-old man with purulent inflammation of the right knee who was admitted to the intensive care unit (ICU) via emergency room orthopedic evaluation because of purulent pericarditis. Subxiphoid pericardiotomy was urgently performed, with 1200 ml of thick purulent fluid evacuated. As prevention for pericardial constriction, it was decided to administer fibrinolysis to the patient's pericardial cavity. Administration of streptokinase was complicated by the occurrence of a severe retrosternal pain and intrapericardial bleeding. Due to insufficiency of antibiotic therapy, 17 days after complicated fibrinolytic therapy with streptokinase, it was decided to administer 20 mg of r-tPA directly into the pericardium. In the following days, there remained a high drainage of purulent secretions. Fever up to 38 °C was still observed despite the use of antibiotics. Nine days after first administration of r-tPA, it was decided to apply the next dose. Daily drainage decreased from 50 to 20 ml in successive days. No fluid accumulation and symptoms and signs of constrictions were observed in clinical examinations as well as in echocardiography performed during 7 years follow-up after discharge.