Abstract
BackgroundThe incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa.MethodsConsecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status.ResultsA total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs.ConclusionPatients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.
Highlights
The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic
What are the implications for clinical practice? Patients with suspected tuberculous pericarditis and HIV infection have evidence of a myopericarditis, poorer functional class, and haemodynamic instability in Africa
These factors are likely to be associated with a poorer prognosis, and may identify a high risk group that requires more intensive management of the cardiac disease and consideration of earlier treatment of the HIV disease
Summary
The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. In Africa, the incidence of tuberculous pericarditis is said to be rising as a direct result of the human immunodeficiency virus (HIV) epidemic [3,4,5,6,7]. There is a strong association between HIV infection and tuberculous pericarditis in endemic regions, where 40–75% of patients with large pericardial effusion (suspected to be tuberculosis) are infected with HIV [2,3]. The effect of HIV infection on the clinical presentation, response to treatment and outcome of patients with tuberculous pericarditis is not well characterised [8]. Preliminary evidence suggests that HIV infection may be associated with higher mortality in tuberculous pericarditis; mortality with anti-tuberculosis chemotherapy ranged from 8% to 17% in the pre-HIV era [9,10,11,12], whereas higher mortality rates of 17–34% have been reported in HIV infected individuals [13]
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