the etiology involved in the genesis of pericardial effusion syndrome ( pes ) is extremely varied . thus , doctors of different specialties may deal with this pathology which , apart from the cardiac decompression therapy , requires a therapy of the main affection generating pes . the etiological variety of pes explains the difference in medical prognosis for the affected patients . by using traditional medical treatment , the internist or cardiologist may succeed in regressing the pericardial effusions , however , very often , it is necessary to use an invasive medical technique either for diagnosis ( obtain pericardial fluid or pericardial tissue fragments for additional lab tests ) or for therapeutic purposes ( pericardial drainage for the decompression of the heart ) . the guidelines for using these invasive strategies , as well as for the lab tests on the intraprocedurally collected specimen , have been partially established by the european society of cardiology guidelines , published in 2004 . there are many controversial aspects referring to the pes diagnosis and therapy , as there are not so far randomized evidence - based prospective studies to state clear recommendations for different diagnostic and therapeutic methods . moreover , new techniques have appeared ( percutaneous balloon pericardiostomy , percutaneous pericardiostomy ) , but they are used in very few medical centers in the world . they require special medical equipment and a certain learning curve and their results are difficult to interpret and to reproduce . very often a pericardiocenthesis is performed by the cardiologist for diagnostic and/or therapeutic purposes . and very frequently , the cardiovascular and thoracic surgeons are consulted in order to decide upon the necessity , the moment of the operation , the surgical procedure of pericardial drainage and contingently upon a different therapy ( resection of a lung tumor , usually for bioptic purposes , pericardiectomy , etc ) . the surgeon finds himself facing many controversies and often having a patient with an associated frame of significant comorbidities . nowadays , there are variable results in the use of various techniques of pericardial drainage ( mini - invasive or invasive ones ) which may be associated with local intrapericardial treatment ( sclerotherapy , chemotherapy ) , with pericardial biopsy guided by pericardioscopy , and rarely , with the performance of a pericardiectomy ( total or partial ) in order to avoid the pes recurrence or a possible evolution towards constrictive pericardial syndrome . 34 year - old patient , d.c , urgently admitted in the clinic of cardiology - craiova , in 2008 false surgical acute abdominal , dyspnea at rest , tachypnea , low fever and asthenia . a patient undergoing oncological treatment for the hodgkin disease , diagnosed a month before admission , was urgently transferred from craiova hematology clinic for progressive epigastric and retrosternal pain in last few days , progressive dyspnea in the last week , presently with dyspnea at rest and tachypnea , accompanied by asthenia for the last 2 months . the patient had had fever ( 38.9 c ) five days before ( cultures from blood and urine were collected and treatment with broad - spectrum antibiotics initiated until a definitive antibiogram result ) . yet nineteen million people have died of aids since the discovery of hiv in the 1980s . in 1999 alone , 5.4 million people were newly infected with hiv ( ref . 1 and http://www.unaids.org/epidemicupdate/report/epireport.html ) . sub - saharan africa has been hardest hit , with more than 20% of the general population hiv - positive in some countries ( 2 , 3 ) . in comparison , heterosexual epidemics in developed , market - economy countries have not reached such severe levels . factors contributing to the severity of the epidemic in economically developing countries abound , including economic , health , and social differences such as high levels of sexually transmitted diseases and a lack of prevention programs . however , the staggering rate at which the epidemic has spread in sub - saharan africa has not been adequately explained . the rate and severity of this epidemic also could indicate a greater underlying susceptibility to hiv attributable not only to sexually transmitted disease , economics , etc . , but also to other more ubiquitous factors such as host genetics ( 4 , 5 ) . clinical examination : skin and mucosal pallor , normal weight , low fever ( 37.9 c ) , reduced adipose tissue , right latero - cervical and axillary poliadenopathy ; respiratory system without clinical modifications ; cardiovascular / circulatory system - tachycardic heart sounds , heart rate ( hr ) = 110 beats / minute , grade 3 jugular turgescence , ta : 85/60 mmhg ; digestive system  epigastrial and right hypochondrial pain on palpation with muscle defense , grade 1 splenomegaly , normal liver on palpation ; painless flanks ; neurologically - without modifications on objective examination . the peripheral vascular access has been obtained via two veins and usual blood samples were collected for lab tests . the hemodynamic ( bp , pulse , ecg ) and respiratory ( so2 established by skin pulse oxymetry ) monitoring started . the biochemical examination : esr=52 mm / h , fibrinogen=400 mg / dl , crp=12.5 mg.l , hb=11.4 g / dl , thrombocytes= 190000/mm , leucocytes= 15.200/ mm , unsegmented neutrophils=2% , segmented neutrophils= 75% , lymphocytes= 17% , monocytes= 4% , eosinophils= 1% , na=127.3 mmol / l , k= 3.35 mmol / l , cl= 91 mmol / l , ca= 0.709 mmol / l . ecg : electric alternance of the qrs complex , synus tachycardia , + 30 qrs axis , without t wave alternance ( fig . ecg 12 derivations , early re - polarization with electrical alternance , diffuse low voltage . echocardiography : pericardial fluid 33 mm posterior to the lv and 33 mm anterior to the rv ; vci=30 mm . normal lv function . 2 ) echocardiography , 4 chambers apical view , early depolarization , large pes with diastolic collapse of the right cavities . an emergency subxyfoid pericardial puncture was performed , under asepsia and local anesthesia with xylocaine : 50 ml of frank purulent fluid could be extracted . the patient respiratory and hemodynamic status is relatively stable under oxygen therapy and volume replacement solutions ( ringer - lactate ) at an average flow without inotropic or vasoactive support . diagnosis : purulent pericarditis with cardiac tamponade , hodgkin disease emergency thoracic surgical consultation was asked for . on entering the pleural cavity , the intense erythematous and under tension pericardium could be observed . a minimum incision is made in the pericardium anterior to the phrenic nerve and the aspirator is introduced . approximately 100 ml frank purulent fluid is aspirated , and then fluid is collected for the bacteriological , cytological and biochemical testing . a 7x7 cm pleuro - pericardial window is created and the pericardium section is sent for the histopathological examination . the rest of the purulent fluid from the pericardial cavity is aspirated and the digital lysis of the false membrane is performed . the pericardial and the pleural cavity are washed with physiological saline solution at body temperature . in the end 2 drainage tubes are inserted into the pericardial and pleural cavities respectively , and exteriorized separately though a counter - incision in the inferior intercostal space and connected to low aspiration . the biochemical examination of the pericardial fluid shows : proteins = 5.2 g / dl , a positive rivalta reaction , glucose= 80 mg / dl . the cytological examination of the pericardial fluid : frequent polymorphonuclear leucocytes , rare lymphocytes and rare erythrocytes . the bacteriological examination of the pericardial fluid for tb and unspecified germs : no germs developed . after surgery , the patient has been treated in the intensive care unit for 4 days . general therapeutic measures have been applied : hydroelectrolytic balance , analgesics , general antibiotherapy- oxacillin iv 2 g q6h , ceftriaxone iv 2 g q12h , gentamicin iv 80 mg q8h . the pericardial cavity has been continually irrigated with physiological saline solution and gentamicin , intrapleurally and intrapericardially , 3 - 4 times a day , for the first 3 days . removal of drainage took place on the 7th postoperative day , with subsequent immediate radiological control and another control prior to discharge . the patient was discharged 2 weeks after the operation , with signs of normal wound healing , in order to continue the specific treatment of the main disease . the purulent pericarditis is rare nowadays due to the development of antibiotherapy ; it may appear in patients whose immune system is compromised ( leukemia , lymphoma , chronic liver diseases , chronic kidney diseases , diabetes , alcoholism , during the imunosupresive / cytostatic treatment ) , after cardiothoracic surgery , in patients with infective endocarditis or septicemia . the presented case has the following characteristics :  purulent pericarditis in a patient having hodgkin disease under treatment with cytostatic medication . patients with hodgkin disease have a lower cell immunity characterized by anergy to the skin tests   and reverse ratio cd4/cd8 ;  presence of abdominal epigastric pain ( false acute surgical abdomen ) in the acute hypodiastolic syndrome . the abdominal pain in the pericardial effusion with cardiac tamponade appears in 20 - 40 % of the cases , being determined by the distention of the liver capsule during the hypodiastolic syndrome with liver stasis ;  clinical and biological response to infection and inflammation is altered . the cytokines and their antagonists are involved in the response to the infection and inflammation ; the antagonists of the inter - leukin 1 receptors and the tnf alpha - receptors are very high for old people or patients with immunodeficiency . these modifications inhibit the fever reaction and the elevation in the non - specific inflammatory markers . for almost 50 - 60% of the cases having purulent pericarditis , the cultures remain positive , while for the rest of the cases they are negative . for the case presented above , the cultures were not positive , possibly because of the antibiotic treatment the patient had received prior to the bacteriological tests . the evolution of the presented case was favorable due to the early diagnosis and the implementation of specific therapy . the purulent pericarditis diagnosed too late or without specific treatment evolves to toxico - septic complications and death . in the specialty literature , several methods of managing the pericardial drainage are described :  subxyphoid pericardiocentesis by placing a drainage tube intrapericardially and irrigating it periodically with physiological saline solution and , if needed , with antibiotics or fibrinolytic drugs . pericardiocentesis is a minimally - invasive procedure , yet , sometimes it can not evacuate the thick purulent liquid from a pericardial cavity , false membranes often not allowing an efficient drainage . there have been reported about exceptional cases of improved pericardial drainage and implicitly of recovery by leaving a catheter in the pericardial cavity and administering local fibrinolytic treatment . there are raports of efficient drainage in purulent pericarditis with the new method of percutaneous balloon pericardiostomy , but there is little experience with it ;  the classic surgical subxiphoid pericardial drainage is preferred , as the surgical trauma is minimal and it avoids the risk of sternal or pleural cavity contamination , risks associated with the median sternotomy and thoracotomy . the disadvantage is that it can not evacuate posterior fluid loculations and does not allow an extended pericardiectomy , reasons why some authors recommend it only for patients in critical condition , to whom a thoracotomy or a median sternotomy would be too aggressive . concomitant use of intraoperative pericardioscopy would probably outset this disadvantage ;  the pleuro - pericardial window by anterior thoracotomy or vats is an efficient pericardial drainage method . there are authors who mention relative contraindications   but there are other authors who report satisfactory results ;  the external pericardial window by median sternotomy . it has the advantage of an excellent pericardial exposure , facilitating the lysis of adhesions and the evacuation of loculated purulent fluid . nevertheless , there is the risk of sternal contamination which may cause high post - surgery morbidity ;  in cases with a local tendency to fibrosis and high fibrin content in the pericardial fluid , the pericardiectomy is sometimes recommended in order to avoid the evolution towards a pericardial constriction . performing the pericardiectomy and it implies an antero - lateral thoracic approach ( thoracoscopic video - assisted also possible ) or though a median sternotomy . if both procedures are performed simultaneously , they associate the risk of pleural or sternal contamination ( more fearful ) , as well as the risk of a more aggressive intervention ( longer operative time and a greater risk of bleeding ) . in the presented case , it was decided upon a pericardial drainage by left anterior thoracotomy with simultaneous partial anterior pericardiectomy to avoid the risk of an evolution towards a pericardial constriction and to be able to perform an efficient  under view  , open drainage , with the lysis of the pericardial adhesions . a month after surgery , the patient was received in the ambulatory : no recurrence of empyema , sound wound healing , good general status . there was the risk of a cardiovascular decompensation at anesthesia induction , but the patient remained hemodynamically stable , using only the volume replacement therapy . the following drugs should be avoided in the pericardial effusion with cardiac tamponade : vasodilators , drugs decreasing the heart rate and drugs decreasing plasma volume ( furosemide ) . the positive - pressure mechanical ventilation and the positive peep is recommended to be performed cautiously , as , by increasing the intrathoracic pressure , the preload is decreased and hypotension may supervene , with shock and death . the positive inotropic agents are used for treating the hypotension installed before or after pericardial drainage together with drugs that restore the plasma volume .
purulent pericarditis is rarely encountered in the antibiotherapy era , mainly in immunosupressed patients , after cardiac operations , in septicemia . 
 diagnosis of purulent pericarditis is based upon the analysis of pericardial drainage , obtained through pericardiocentesis or preferably , through a surgical approach . 
 the reported case has following peculiarities : clinical signs of false acute surgical abdomen ; altered clinical and biological response to infection ; optimal treatment is early , efficient pericardial drainage , with low risk of tissue contamination and of pericardial constriction ; surgical subxyphoid pericardial drainage is prefered in patients with affected general status . 
 antero-(lateral ) thoracic approach with associated anterior pericardiectomy ensures an efficient pericardial drainage and prevents pericardial constriction , with low risks for pleural contamination .