Purulent pericarditis is an infection in the pericardial space producing purulent fluid¹. It was historically a complication of pneumococcal pneumonia. In the modern antibiotic era, it is rare ² and also due to a bloodstream infection.

It is more common with predisposing factors including recent thoracic surgery, chest trauma, chronic renal failure, malignancy, alcohol abuse and pre-existing pericardial disease ^2,3.

Direct spread can result from virtually any organism but the most common is Streptococcus pneumoniae. Hematogenous spread is most common with S. aureus and Strep spp. Spread from infective endocarditis is possible. Perforating injury or surgery is also a possible source of infection. S. aureus is the most common pathogen overall². The usual presentation consists of high fever, tachycardia, cough, and chest pain.

This patient had disseminated MRSA infection including purulent pericarditis and empyema. He had clinical signs and symptoms suggestive of pericardial effusion and early tamponade. The effusion was drained but reaccumulated and the patient underwent pericardiectomy and completed several weeks of intravenous antibiotics.

As identified on the CT, he had left internal jugular thrombosis. He was also found to have left 1st costochondral junction osteomyelitis.

This case shows the unusual fashion in which purulent pericarditis presents but also highlights the unusual presentations of IVDU patients who often have serious pathology presenting in a less overt manner.