Transdiaphragmatic Extension of a Pyogenic Liver Abscess Causing Purulent Pericarditis With Cardiac Tamponade in Septic Shock: A Case Report.

Purulent pericarditis is a rare, life-threatening condition in the post-antibiotic era, accounting for fewer than 1% of pericardial diseases, and may progress to cardiac tamponade. Transdiaphragmatic spread from a hepatic abscess is an exceedingly rare mechanism of infection. This case report highlights the unusual invasive potential of Eikenella corrodens in a polymicrobial infection that crossed anatomical barriers. A 41-year-old man with a history of gastric sleeve surgery three years earlier presented with refractory septic shock and cardiac tamponade. Emergent ultrasound-guided pericardiocentesis with pericardial drain placement yielded 880 mL of purulent fluid. Concurrent CT imaging revealed a large hepatic abscess at the diaphragmatic dome with direct transdiaphragmatic continuity to the pericardium, highlighting a rare anatomical route of contiguous spread and providing a mechanistic explanation for the purulent pericardial infection. Cultures grew Eikenella corrodens  and Streptococcus anginosus . Management included pericardial drainage, image-guided percutaneous drainage of the hepatic collections for source control, prolonged pathogen-directed antimicrobial therapy, and therapeutic anticoagulation for pulmonary embolism. This case report describes a rare, life-threatening combination of septic shock, multiple pyogenic liver abscesses, purulent pericarditis with cardiac tamponade, and pulmonary embolism. Successful management required coordinated multidisciplinary care, including urgent pericardial drainage for source control and relief of hemodynamic compromise, prolonged pathogen-directed antimicrobial therapy guided by microbiology, and carefully timed anticoagulation for pulmonary embolism while balancing the competing risks of thrombosis and bleeding in the setting of concurrent cardiac tamponade.