Fig.1: 2DE shows fibrinous pericardial effusion with loculation (arrow).

Fig.2: 2DE shows resolution of pericardial fluid.

A one-year-old female patient from Bangladesh was admitted because of a history of fever. Past medical and surgical histories were not significant. Her clinical exam was consistent with tachycardia and muffled heart sounds. Chest X-ray showed cardiomegaly; ECG revealed low voltage with generalized S-T elevation; CBC and acute phase reactants were suggestive of bacterial infection. Echocardiogram (Fig.1) showed large (15mm) fibrinous pericardial effusion with loculations, near normal biventricular function and no signs of tamponade. Pericardiocentesis was performed. Gram stain of this fluid showed Gram positive cocci and culture was positive for staphylococcus aureus. Broad spectrum antibiotic coverage was given for 15 days but patient remained febrile with no change in echo findings. Surgical pericardiotomy was performed after 15 days of antibiotic treatment. A significant amount of cheesy material was removed and histopathology of pericardial tissue showed acute suppurative inflammation with granulation tissue, no granulomas, no malignancy. Patient improved clinically, by CBC/acute phase reactants and echocardiographically (Fig.2) and a total of 4 weeks antibiotic course was completed. The patient was discharged in good condition.