Tamponade with a thickened pericardium

Abstract

A 24-year-old Caribbean man, with no previous medical history, presented with cough, dyspnoea, and weight loss of 6 kg over the previous month. He reported a 2-month history of night sweats without fever. Physical examination revealed breath frequency of 40 breaths per min and a tachycardia of 121 beats per min, with soft heart sounds and ankle oedema. Laboratory fi ndings showed a normal complete blood count and C-reactive protein of 107 mg/L. HIV serology was negative. Echocardiography found a tamponade with a thickened pericardium (6 mm), confi rmed by a contrast-enhanced thoracic CT scan (fi gure). Aspiration of fl uid from the pericardium yielded 2 litres of fl uid. Pericardial biopsy showed caseous necrosis. Cultures and PCR were positive for Mycobacterium tuberculosis in the pericardial fl uid. Disseminated pulmonary involvement was found on lung-windowed CT scan. The patient was given antituberculous treatment combining isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, then isoniazid and rifampicin for the following 4 months. Corticotherapy was started at the same time as the antituberculous treatment, consisting of prednisone 1 mg/kg per day for 1 month tapered over the following 2 months. The patient remains disease-free after 26 months. Pericardial involvement is seen in up to 2% of patients with pulmonary tuberculosis. Tamponade is a frequent presentation in tuberculous pericarditis, happening in almost 90% of cases. Besides positive cultures, other important features for positive diagnosis are fever and night sweats, weight loss, serum globulin (greater than 40 g/L), and peripheral blood leukocyte count (less than 10×10 cells per L). Some investigators suggest that pericardial interferon γ, when available, is a useful diagnostic test with a better positive predictive value than pericardial adenosine deaminase. The use of corticosteroids in the treatment of tuberculous pericarditis needs further discussion. A small study has revealed that corticosteroids reduce complications in patients not infected with HIV. However, more studies in larger populations and in patients infected with HIV are warranted to better assess the role of corticosteroids in tuberculous pericarditis.