An acute presentation of tuberculous pericarditis: Diagnosis and management

Abstract

Aims/objectives: Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, with pulmonary and extra-pulmonary manifestations; cardiovascular involvement is rare, estimated to occur in less than 8% of cases. Material and methods: A 27-year-old Indian man, with no known history of cardiac disease, presented with a 4-week history of left sided chest pain. He had associated shortness of breath, weight loss and fevers. His sister had recently been diagnosed with a tuberculous abscess, but the patient had declined participating in contact tracing. Results: Initial bloods showed a negative troponin, elevated CRP, positive Elispot and negative for HIV. The chest radiograph identified a new cardiomegaly. Electrocardiogram (ECG) demonstrated a micro-voltage tachycardia and subsequent echocardiogram identified a large circumferential pericardial effusion with early signs of tamponade. The chest computed tomography (CT) identified associated mediastinal lymphadenopathy. The patient was transferred and underwent surgical pericardial drainage and window (approximately 900 mL). The patient was started on empirical quadruple anti-tuberculous therapy and a high dose oral steroid as per current guidelines. Pericardial fluid was culture negative, with cytology revealing lymphocytes. On follow-up, symptoms were resolving and subsequent chest radiograph demonstrated no evidence of cardiomegaly. Discussion and conclusion: Tuberculous pericarditis is extremely rare in western countries but may still present in migrant populations. It is a diagnostic and treatment challenge; with a high untreated mortality rate, extremely difficult to confirm a diagnosis and very little evidence based treatment.