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Asian Cardiovasc Thorac Ann 2001;9:334-335
© 2001 Asia Publishing EXchange Pte Ltd

CASE STUDY

Use of Streptokinase in Fibrinous Purulent Pericardial Effusion

Hasim Üstünsoy, MD, Muammer Cumhur Sivrikoz, MD, Metin Topal, MD, Kutluhan Yilmaz, MD1, Bülent Koçer, MD

Department of Cardiovascular and Thoracic Surgery
1 Department of Pediatric Diseases Gaziantep University School of Medicine Gaziantep, Turkey
For reprint information contact: Hasim Üstünsoy, MD Tel: 90 342 336 5400 Ext. 267 Fax: 90 342 336 5505 email: hustunsoy{at}yahoo.com Department of Cardiovascular and Thoracic Surgery, Gaziantep University School of Medicine, Kolejtepe, Gaziantep 27070, Turkey.

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A 7-year-old girl presented with fibrinous purulent pericardial effusion secondary to Staphylococcus aureus osteomyelitis. Poor drainage was achieved by pericardiocentesis, but intrapericardial fibrinolytic therapy with streptokinase restored effective drainage and the patient recovered rapidly.


   INTRODUCTION
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 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
A loculated exudate with a high fibrin content causes drainage problems in both pericardial and pleural effusions.1–3 Although fibrinolytic therapy has been available for many years, its use in pericardial effusions is limited. We speculated that such treatment might eliminate the need for pericardiectomy.


   CASE REPORT
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 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 7-year-old girl suffered pain and swelling in the right ankle and chest pain, as a result of falling from a height. On admission, her general condition was moderate, she was conscious with tachypnea and dyspnea. Her blood pressure was 100/80 mm Hg, she had a temperature of 37°C, heart rate of 120 beats•min-1, and intact peripheral pulses. Heart sounds were muffled, and rales and rhonchi could be heard. An abscess was developing on the right leg. Routine laboratory tests were normal except for leukocytosis and an increased erythrocyte sedimentation rate. An electrocardiogram demonstrated sinus tachy-cardia, and chest radiography showed enlargement of the cardiac contours and an increase in the density of the lung shadows in the lower lobes. Echocardiography revealed pericardial fluid rich in fibrin (left ventricular end-diastolic diameter, 2.5 cm; right ventricular end-diastolic diameter, 1.5 cm), compression of the left ventricle, and paradoxical ventricular septal movement (Figure 1Go). Pericardiocentesis was performed under echocardiographic guidance. A catheter was placed by a subxiphoid approach under local anesthesia, and 200 mL of purulent fluid was drained. Cultures of pericardial fluid and samples from the right leg lesion were positive for Staphylococcus aureus; antibiotic therapy was planned accordingly. Biochemical analysis of the fluid showed a high level of lactic dehydrogenase and a low glucose concentration. Peri-cardial drainage ceased on the 2nd day. In order to lyse the fibrin, 2,000 units of streptokinase in 50 mL normal saline was administered by catheter into the pericardial space daily for 5 days.3 The catheter was clamped for one hour following the injection, and free drainage was continued afterwards. Drainage of pericardial fluid containing fibrin particles resumed at a rate of 150 mL per day and gradually tapered off. Echocardiography on the 5th day showed a decrease in pericardial effusion and the amount of fibrin. As the catheter was occluded, it was replaced by one with a wider lumen. Streptokinase was continued for 3 more days at the same dosage, and drainage of 60 mL per day was obtained. The drain was removed on the 10th day as the status of the patient had improved, cultures were negative, the cardiac contours had returned to normal on telecardiography, and echocardiography showed an absence of pericardial fluid. On follow-up at one month, laboratory tests and telecardiography were negative, and echocardiography showed no pericardial thickening or effusion (Figure 2Go).



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  		Figure 1. Echocardiogram on admission showing collection of intrapericardial fluid with a high content of fibrin. LV = left ventricle, PE = pericardial effusion, RV = right ventricle.

 


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  		Figure 2. Follow-up echocardiography after one month showing no pericardial thickening or effusion.

 

   DISCUSSION
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 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
Schuh4 first performed pericardiocentesis in 1840, but this intervention carried high morbidity until the 1970s. With echocardiographic guidance, mortality and morbidity have decreased substantially, and pericardiocentesis has become a viable alternative to the surgical technique.5 Pericardial effusions can be caused by several etiological factors including infectious agents.5 Staphylococcus aureus is a common cause of purulent pericardial effusions. Pericardiocentesis is recommended as the first treatment option. When adequate drainage cannot be established, a pericardial window can be tried before undertaking a pericardiectomy.6 In this patient who had severe intrapericardial fibrin accumulation, application of streptokinase resulted in effective drainage and avoided further procedures.

Streptokinase exerts its fibrinolytic effect by converting plasminogen to plasmin. There are several adverse effects of fibrinolytic therapy, including allergic reactions, yet no systemic side effects due to absorption from the pleural or pericardial spaces have been reported.2 Streptokinase has been used for the treatment of pleural effusions for nearly 30 years; however, reports of streptokinase therapy for pericardial effusion with a drainage problem are quite limited. On the basis of our experience of streptokinase in loculated emphysema, it was postulated that it might be helpful in this case where intrapericardial fibrin accumulation was implicated in the drainage problem. The successful outcome in this patient suggests that when effective drainage cannot be achieved by pericardio-centesis, fibrinolytic therapy should be tried before contemplating surgery. The efficacy of this treatment should be investigated in a larger group of patients.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Rosen H, Nadkarni V, Theroux M, Padman R, Klein J. Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients. Chest 1993; 103:1190–3.[Abstract/Free Full Text]

  2. Aye RW, Froese DP, Hill LD. Use of purified streptokinase in empyema and hemothorax. Am J Surg 1991;161: 560–2.[Medline]

  3. Cross JH, De Giovanni JV, Silove ED. Use of streptokinase to aid in drainage of postoperative pericardial effusion. Br Heart J 1989;62:217–9.[Abstract/Free Full Text]

  4. Schuh F. Erfahrungen über die Paracentese der Brust und des Herz-beutels. Medizinisches Jahrbuch des kaiserlichen und königlichen Staates Wien 1841;33:388.

  5. Bastian A, Meissner A, Lins M, Siegel EG, Moller F, Simon R. Pericardiocentesis: differential aspects of a common procedure. Intensive Care Med 2000;26:572–6.[Medline]

  6. Kirklin JW, Barratt-Boyes BG. Cardiac surgery. New York: Churchill-Livingstone, 1993:1683–98.





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