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A 61 year old woman with longstanding rheumatoid arthritis presented with a two month history of increasing breathlessness. On examination she had a raised jugular venous pressure, pitting oedema to the umbilicus, and dullness at the right lung base. There was clinical concern of pulmonary embolus so a computed tomography (CT) pulmonary angiogram was performed. This showed a moderate right pleural and pericardial effusions with no evidence of pulmonary emboli. Over the next few days the patient became septic with no obvious cause. Transthoracic echocardiogram on two occasions demonstrated what appeared to be only a small pericardial effusion. Staphylococcus aureus was grown from blood cultures and a repeat CT (right) performed on a 16 detector multislice CT showed a loculated posterior pericardial abscess (note subtle pericardial enhancement) compressing the ventricular outflow (VO) and causing severe tamponade. The posterior location probably accounts for the underestimation on echocardiography.
Using CT guidance, a 12 French pigtail drain was inserted into the pericardial space; 400 ml of purulent blood stained fluid was removed and subsequent culture grew S aureus. The patient made an initial good recovery, but the pericardial collection reaccumulated and needed further drainage.