A Rare Case of Purulent Pericarditis: Group A Streptococcus Causing Cardiac Tamponade

Introduction: Purulent pericarditis is a life-threatening condition characterized by the accumulation of pus within the pericardial sac. While common causative organisms include Staphylococcus aureus, Streptococcus pneumoniae, and gram-negative bacteria, Group A Streptococcus (GAS) remains a rare but increasingly recognized pathogen in immunocompetent adults. Clinical presentation is often nonspecific and there is a high risk of rapid progression to cardiac tamponade. If left untreated, the condition is frequently fatal. However, early recognition and timely intervention can significantly improve outcomes.


Description: A 70-year-old male presented with shortness of breath and difficulty managing secretions following a recent esophagogastroduodenoscopy (EGD) due to dysphagia with concerns for possible esophageal cancer. Despite receiving a fluid bolus, broad-spectrum antibiotics, vancomycin and cefepime, and vasopressors, the patient remained hemodynamically unstable. CT chest revealed a 21mm pericardial effusion. Bedside echocardiogram confirmed a moderate circumferential effusion with tamponade physiology including right ventricular compression and a dilated inferior vena cava. Given concern for malignant pericardial effusion, the patient underwent an emergent surgical pericardial window, draining 200cc of serosanguinous fluid. Pericardial fluid cultures grew GAS, while cytology was negative for malignant cells. Blood cultures also grew GAS. As a result, ceftriaxone was initiated for a planned four week course. Biopsies from EGD later confirmed metastatic esophageal adenocarcinoma. The patient was stabilized and was eventually transitioned to step-down care.


Discussion: Patients with purulent pericarditis often have poor clinical outcomes. Despite treatment, up to 40% of patients die from complications such as tamponade, constrictive pericarditis, or sepsis. This case highlights a rare but life-threatening presentation of purulent pericarditis caused by GAS, an uncommon etiology of pericardial infection, particularly in the setting of underlying malignancy. While malignant pericardial effusions are more common in patients with cancer, cytology was negative and cultures confirmed GAS, emphasizing the need to maintain a broad differential.