A 15-year-old girl had a cough of 2½ weeks' duration and gradual onset of dyspnea and tachypnea. Physical examination disclosed the following values: oral body temperature, 38.9 °C; respirations, 30/min; pulse rate, 120 beats per minute; and BP, 90/60 mm Hg, with a paradoxical pulse of 20 to 40 mm Hg. There were bilateral pulmonary basilar rales, muffled heart sounds, and an enlarged tender liver that extended 4 cm below the right costal margin. Chest roentgenograms were obtained (Figure).
Denouement and Discussion
Roentgenograms of chest in upright posteroanterior (left) and lateral (right) projections show enlarged cardiac silhouette with pericardial air-fluid level.Purulent pericarditis with substantial cardiac dysfunction was suspected, and a pericardial drain was inserted. Culture of both the pericardial fluid and blood yielded Peptostreptococcus and Bacteroides fragilis, both anaerobic organisms. Despite initial improvement with the aid of antibiotics, there were subsequent signs of cardiac tamponade and the