Purulent Pericarditis After Esophageal Erosion With Streptococcus intermedius and Lactobacillus spp

Purulent pericarditis is rare but rapidly fatal without urgent drainage and targeted antibiotics; malignancy-related effusions should not be presumed malignant when an anatomic breach is possible.

A 67-year-old male with esophageal squamous cell carcinoma presented with pleuritic chest pain. Electrocardiogram showed diffuse ST elevation; transthoracic echocardiography revealed a large effusion with fibrinous strands and mild right-ventricle diastolic collapse. Computed tomography angiography demonstrated tumor erosion into the left main bronchus. The patient received vancomycin/piperacillin-tazobactam and underwent emergent pericardiocentesis yielding ∼800 mL of cloudy fluid (49,710 cells/μL, glucose 2 mg/dL, lactate dehydrogenase 7,327 U/L; neutrophil predominant; cytology negative; blood cultures returned negative). Cultures grew Streptococcus intermedius and Lactobacillus spp; antibiotics were narrowed to intravenous ceftriaxone for 3 weeks. Persistent tamponade necessitated pericardial window placement on hospital day 4; follow-up echocardiography demonstrated improved effusion with pericardial thickening/calcification.

In malignancy, diffuse ST elevation and highly inflammatory fluid should prompt evaluation for purulence and an anatomic breach rather than anchoring on malignant effusion.

In cancer patients with pericardial effusion, oral/gastrointestinal flora in pericardial cultures should trigger evaluation for an anatomic breach (eg, tumor erosion) and early source control with drainage, culture-directed antibiotics, and surgical escalation when tamponade continues to persist.