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

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.