“Pus Somewhere, Pus Nowhere Else, Pus above the Diaphragm”-Pediatric Pericarditis Puzzling Professionals

Case Report

Austin J Clin Case Rep. 2014;1(6): 1030.

“Pus Somewhere, Pus Nowhere Else, Pus above the Diaphragm”-Pediatric Pericarditis Puzzling Professionals

Govani DR1, Scott V2, Kumar H3, Patel RR4, Patel RV5* and Vaghela SV6

1Medical Student, University of Birmingham Medical School, UK

2Department of Ped Surgery, Royal Alexandra Children’s Hospital, Brighton, UK

3Department of Ped Surgery, Patan Academy of Health Sciences, Nepal

4Department of Pediatrics (AM), Saurashtra University, India

5Department of Ped Surgery, Saurashtra University, India

6Department of Cardiothoracic Surgery, Saurashtra University, India

*Corresponding author: Patel RV, Department of Surgery, Postgraduate Institute of Child Health and Research and KT Children Government Hospital, Saurashtra University, Rajkot 360001, Gujarat, India

Received: June 28, 2014; Accepted: July 22, 2014; Published: July 24, 2014


A case of acute septicaemia in an 18-month-old girl is presented in whom the general surgical approach of the classic aphorism ‘pus somewhere, pus nowhere else, pus under the diaphragm’ proved nothing but a distraction. The child had several professionals involved in her care and multiple investigations including chest and abdominal radiographs, ultrasound scans, and a computerised axial tomogram of the torso failed to detect the problem. She also underwent 3 operative procedures including a diagnostic laparoscopy with incidental appendectomy, exploratory laparotomy with mesenteric lymph node biopsy and insertion of a central line by a general surgeon and a second line insertion. In total she received 4 general anesthetics under continuous EKG monitoring. She was given courses of multiple antibiotic combinations without clinical improvement. She was finally referred to us at the children hospital with cardiac services to rule out a cardiac cause after 2 weeks of investigation and unsuccessful treatment. In addition to classic clinical, laboratory, EKG and imaging investigations done earlier showing clear features of gross pericarditis, she underwent an echocardiogram which confirmed gross purulent pericarditis. This responded well to percutaneous image guided drainage under antibiotic cover. This case highlights changing trends of infections at very young age and that the classic general surgery aphorism may not be applicable to this group of patients. Moreover, this case is a reminder of the dictum that a child should not be considered a miniature form of the adult and general surgical principles may not be applicable to them. It demonstrates that younger children need special expertise and although several professionals from various specialities even with a pediatric interest were involved and numerous investigations were performed, centred on the abdomen, the team was cognitively blocked to look at the evidence on the other side of the diaphragm- the eyes cannot see what the mind does not know. Even the pediatric team had difficulty identifying the problem as cardiology services were based at the cardiac hospital on a different geographical site; hence team did not have routine exposure and practice. It highlights the fact that patient safety and quality of care is still lacking in developing countries even in the twenty first century due to obscure referral pathways, lack of specialist services and geographical isolation.

Keywords: Bacterial; Children; Pericarditis; Pericardiocentesis; Echocardiography; Diaphragm


The symptoms and signs of infection at the lower and upper age limits of life, in the pediatric and geriatric populations, are frequently nonspecific. In general surgery, it is recommended to remember the well-known aphorism of “pus somewhere, pus nowhere else, and pus under the diaphragm” [1-3]. Our case is a strong reminder of the facts that it could be above the diaphragm and that what the mind does not know the eyes cannot see.

Case Presentation

An 18-month-old girl presented with an acute infectious illness of short duration of 5 days, characterised by the non specific symptoms of a runny nose, high swinging pyrexia and rigors associated with anorexia, reduced oral intake and irritability. She was seen by her family doctor and diagnosed with an acute viral illness and given oral analgesics and amoxicillin to which she did not respond. She had one episode of vomiting and diarrhoea in these 5 days of acute severe illness.

She was subsequently admitted to the district hospital. She was unwell, pale, febrile, tachycardic and tachypneic. Her chest was clear and her abdomen soft and non-tender. Urine dipstick and microscopy was normal. Laboratory investigations including renal and liver functions were normal but the inflammatory markers were raised with a C-reactive protein (CRP) of 307 mg/L, white cell count 24.4 X 109/L, polymorphs 19.82X109/L and hemoglobin of 89 G/L. All bacteriological investigations, including lumbar puncture for cerebrospinal fluid (CSF), urine, stool, and blood and swab cultures were negative. A chest radiograph showed clear lung fields and although an enlarged cardiac shadow and increased cardiothoracic ratio are clearly evident, it was reported to be normal (Figure 1). Abdominal radiograph showed features of febrile ileus (Figure 2).