Purulent Pericardial Effusion: An Elusive Diagnosis

Purulent pericardial effusion (PPE) is a life-threatening infection of the pericardial space. While rare in the modern antimicrobial era, its rapidly progressive course, diagnostic challenges, and lack of management guidance make it a source of significant morbidity and mortality. Gram-positive bacteria are the most common causative organisms; however, polymicrobial and fungal infections are being increasingly recognized. Rapid diagnosis requires a high index of suspicion supported by clinical findings, pericardial fluid analysis, and imaging studies. Prompt drainage of the infected pericardial fluid along with early antimicrobial therapy remain the cornerstones of management, although gaps on optimal treatment duration, need for surgical intervention, and follow-up persist. This review aims to bridge some of these gaps by examining the current literature on purulent pericardial effusion, highlighting the epidemiology, microbiology, clinical manifestations, diagnostic challenges, management strategies, and both short-term and long-term outcomes of this deadly condition.