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We present a case of a 68-year-old man who presents with worsening cough and dyspnoea 12 months after undergoing radiofrequency ablation therapy for atrial fibrillation. Investigation revealed complete occlusion of the left lower pulmonary vein and partial stenosis of the left upper pulmonary vein. He underwent a stage surgical resection with the first stage being a left lower lobectomy for the non-viable lobe followed by a repair of the left upper pulmonary vein via anastomosis with the left atrial appendage. This staged procedure yielded excellent results and avoided the need for a left-sided pneumonectomy.

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Background Cardiac tamponade is the most feared manifestation of purulent bacterial pericarditis (PBP), a rare form of pericarditis in immunocompetent adults. PBP remains a diagnostic challenge given its atypical associated clinical and investigative features. Consequently, PBP carries exceedingly high mortality rates due to fulminant sepsis, and morbidity including constrictive pericarditis in survivors. We present our management of a patient presenting with cardiac tamponade, who subsequently developed constrictive pericarditis due to Actinomyces meyeri PBP. Source control and symptom relief was achieved only with combined intravenous antibiotics, surgical evacuation and pericardiectomy. Case summary A 53-year-old Caucasian male presented with acute New York Heart Association Class IV symptoms, on an 8-week history of recurrent pericarditis presumed secondary to recent viral infection. Initial transthoracic echocardiography (TTE) demonstrated a large asymmetric pericardial effusion for which he underwent urgent pericardiocentesis. Unexpectedly, repeat TTE demonstrated effusion re-accumulation and effusive-constrictive pericarditis, confirmed on cardiac magnetic resonance imaging. Fluid culture was positive for Actinomyces meyeteri. He was diagnosed with primary PBP and deteriorated despite appropriate intravenous antibiotic therapy, necessitating semi-urgent surgical pericardiectomy. He recovered well and was discharged home day 10 postoperatively. Discussion Unlike uncomplicated acute viral or idiopathic pericarditis, PBP portends a very poor prognosis if unrecognised and untreated. Diagnostic challenges persist given its rarity in modern clinical practice, however PBP should be considered in cases of seemingly recurrent pericarditis. Multi-modal cardiac imaging and careful analysis of pericardial fluid including cultures and lactate dehydrogenase/serum ratios may assist in earlier recognition.

Penetrating chest trauma is associated with significant morbidity and mortality due to direct injury to vital organs located within the thorax. This is a case of a 53-year-old man who presented with a self-inflicted penetrating chest trauma using a solar powered garden light. The light penetrated the left side of his chest resulting in a haemopneumothorax, diaphragmatic perforation and pericardial haematoma. The patient underwent an urgent explorative thoracotomy for the removal of the garden light, repair of the diaphragmatic perforation and wedge resections of the perforated lung parenchyma. Postoperatively, the patient recovered in the intensive care before being transferred to the psychiatric department.