PERICARDIAL TB CAUSING RESTRICTIVE CARDIOMYOPATHY TREATED WITH RIFAMPIN, ISONIAZID, PYRAZINAMIDE, ETHAMBUTOL (RIPE) AND CORTICOSTEROIDS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pericardial tuberculosis presents in one to two percent of pulmonary tuberculosis (TB). Of these patients, approximately thirty to sixty percent develop constrictive pericarditis without treatment. This case presents a patient with constrictive pericarditis from reactivation of a prior pleural TB infection, treated with RIPE therapy and adjunctive steroids. CASE PRESENTATION: An 81 year old male from India with a history of pleural TB (treated with isoniazid, para-aminosalicylic acid and an unknown agent) and recent diagnosis of a large pericardial effusion without tamponade who presented with dyspnea. On presentation, he was hemodynamically stable. Physical exam was unremarkable. Labs significant for c-reactive protein of 166 mg/L and BNP of 508 pg/mL. Echocardiogram showed a small pericardial effusion with new constrictive pericarditis. Work up included a heart catheterization, consistent with constrictive physiology. Cardiac MRI revealed pericardial thickening, adhesions and fibrosis. A thoracoscopy with pericardial biopsy was performed and was negative for mycobacterium tuberculosis (MTB). Bronchoscopy with bronchoalveolar lavage was negative for MTB, however induced sputum post-bronchoalveolar was positive. He was treated with two months of RIPE therapy followed by four months of Isoniazid and Rifampin, in addition to prednisone 60 mg daily with a taper and Bactrim for Pneumocystis Jiroveci prophylaxis. After treatment initiation, sputum testing was negative. Repeat echocardiogram showed resolution of pericardial effusion without constriction. The patient tolerated treatment without complications. DISCUSSION: Tuberculosis pericarditis is diagnosed when any MTB is detected in the body in the setting of pericarditis. In this case, the patient underwent an extensive workup which revealed findings consistent with constrictive pericarditis, however the relation to tuberculosis was not established until his post-bronchoalveolar sputum despite negative pericardial biopsy. Negative pericardial biopsy results cannot rule out tuberculosis pericarditis as the sensitivity ranges from ten to sixty-four percent. A pericardiocentesis on initial presentation may have been helpful in an earlier diagnosis. Standard treatment is RIPE. However, the role of corticosteroids is controversial. Research supports the use of corticosteroids in patients who have or are at high risk of developing constrictive pericarditis. These patients include those with large pericardial effusions, high levels of inflammatory cells in pericardial fluid, and/or early signs of constriction. Corticosteroids have not become standard therapy due to significant side effects, with unclear benefits. CONCLUSIONS: Tuberculosis pericarditis is a rare and challenging diagnosis. Recommended treatment is with RIPE and the role of adjunct corticosteroids warrants further investigation. REFERENCE #1: Larrieu AJ, Tyers GF, Williams EH, Derrick JR. Recent experience with tuberculous pericarditis. Ann Thorac Surg 1980; 29:464. REFERENCE #2: Komsuoglu B, Goldeli O, Kulan K, Komsuoaylu SS. The diagnostic and prognostic value of adenosine deaminase in tuberculous pericarditis. Eur Heart J 1995; 16:1126. REFERENCE #3: Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147. DISCLOSURES: No relevant relationships by Adetokunbo Adebayo, source=Web Response No relevant relationships by Alissa Ali, source=Web Response No relevant relationships by Jared Beaudin, source=Web Response No relevant relationships by Julie Nguyen, source=Web Response