Tuberculosis Pericarditis Research Articles

Tuberculosis pericarditis: a case report

Tuberculosis (TB) is still prevalent in the world. In 2020, 1.5 million people died from TB.18 TB accounts for 4% of acute pericarditis. Tuberculous pericarditis (TBP) is due to hypersensitivity to tuberculin protein produced by Mycobacterium tuberculosis and develops in 1-2% of pulmonary TB cases, representing about 1-2% of extrapulmonary tuberculosis. Complications occur in the form of acute pericarditis (4%) and cardiac tamponade (7%), which may require life-saving invasive procedures. Tuberculous pericarditis has an overall mortality rate of 1.43 per 100 person-months over a median follow-up of 11.97 months. Risk factors include diabetes, substance use disorder, HIV-positivity, renal insufficiency, biological or immunosuppressive therapy, and exposure to regions with a high prevalence of tuberculosis. We present a 49-year-old diabetic male with a large complex pericardial effusion occurring three months after a diagnosis of TB pleurisy on antituberculosis drugs, which required pericardiocentesis and pericardial window in the context of cardiac tamponade. Cases of TB pericarditis in developed countries are rarely reported, and there are even fewer in the US. Along with a literature review of the road map for its accurate diagnosis and treatment, this case highlights the relevance of TB in the differential of pericarditis worldwide, even in developed countries.

Novel role of cardiovascular MRI to contextualise tuberculous pericardial inflammation and oedema as predictors of constrictive pericarditis.

Tuberculosis (TB) and human immunodeficiency virus/acquired immunodeficiency syndrome have reached epidemic proportions, particularly affecting vulnerable populations in low- and middle-income countries of sub-Saharan Africa. TB pericarditis is the commonest cardiac manifestation of TB and is the leading cause of constrictive pericarditis, a reversible (by surgical pericardiectomy) cause of diastolic heart failure in endemic areas. Unpacking the complex mechanisms underpinning constrictive haemodynamics in TB pericarditis has proven challenging, leaving various basic and clinical research questions unanswered. Subsequently, risk stratification strategies for constrictive outcomes have remained unsatisfactory. Unique pericardial tissue characteristics, as identified on cardiovascular magnetic resonance imaging, enable us to stage and quantify pericardial inflammation and may assist in identifying patients at higher risk of tissue remodelling and pericardial constriction, as well as predict the degree of disease reversibility, tailor medical therapy, and determine the ideal timing for surgical pericardiectomy.

GeneXpert MTB/RIF Ultra vs Unstimulated Interferon γ (IRISA-TB) for the Diagnosis of Tuberculous Pericarditis in a Tuberculosis-Endemic Setting.

Tuberculous pericarditis (TBP) is a paucibacillary disease, where host biomarkers such as unstimulated interferon γ (IRISA-TB) have high diagnostic accuracy. However, DNA-based diagnostic tests (GeneXpert Ultra), more sensitive than an earlier versions, have recently become available. Given that the diagnosis of TBP is challenging, we performed a comparative diagnostic accuracy study comparing both assays. We recruited 99 consecutive patients with suspected TBP in Cape Town, South Africa. Definite TBP was defined by microbiological confirmation of tuberculosis (TB) on pericardial fluid culture or an alternative polymerase chain reaction-based test (GeneXpert MTB/RIF) or by use of sputum (polymerase chain reaction or culture). Probable TBP was defined as a high clinical suspicion of TB accompanied by anti-TB treatment, while non-TBP was defined as negative microbiological test results for TB without initiation of TB treatment and/or the presence of an alternative diagnosis. There were 39 patients with definite TBP, 35 with probable TBP, and 23 with non-TBP. Approximately 70% of participants who received TB treatment were HIV coinfected. Overall, IRISA-TB was more sensitive than Xpert Ultra (88.6% [95% CI, 74.1%-95.5%] vs 71.5% [55.0%-83.7%], n = 53) and significantly more sensitive in participants who were HIV uninfected (100% [95% CI, 72.3%-100.0%] vs 60% [31.3%-83.2%], P = .03). In patients with definite and probable TBP combined (n = 84), sensitivity was significantly higher with IRISA-TB (77.3% [95% CI, 65.9%-85.8%] vs 37.9 [27.2%-50.0%], P < .0001). A similar pattern was seen in persons who were HIV uninfected (88.3% vs 35.3%, P = .002). Specificity was high for both assays (>95%). Unstimulated interferon γ (IRISA-TB) was significantly more sensitive than Xpert Ultra for the diagnosis of TB pericarditis in a TB-endemic resource-poor setting.

Assessing the hazard of death, cardiac tamponade, and pericardial constriction among HIV and tuberculosis pericarditis patients using the extended Cox-hazard model: Intervention study.

Tuberculous (TB) pericarditis (TBP), a TB of the heart, is linked to significant morbidity and mortality rates. Administering glucocorticoid therapy to individuals with TBP might enhance overall results and lower the likelihood of fatality. However, the actual clinical effectiveness of supplementary glucocorticoids remains uncertain. This study specifically evaluated the effects of prednisolone, prednisolone-antiretroviral therapy (ART) interaction, and other potential risk factors in reducing the hazard of the composite outcome, death, cardiac tamponade, and constriction, among TBP and human immunodeficiency virus (HIV) patients. The data used in this study were obtained from the investigationof the Management of Pericarditis trial, a multicentre international randomized double-blind placebo-controlled factorial study that investigated the effects of two TB treatments, prednisolone and Mycobacterium indicus pranii immunotherapy in patients with TBPin Africa. This study used a sample size of 587 TBP and HIV-positivepatients randomized into prednisolone and its corresponding placebo arm. We used the extended Cox-proportional hazard model to evaluate the effects of the covariates on the hazard of the survival outcomes. Models fitting and parameter estimation were carried out using R version 4.3.1. Prednisolone reduces the hazard of composite outcome (hazrad ratio [HR] = 0.32, 95% confidence interval [CI] = , p < 0.001), cardiac tamponade (HR = 0.14, 95%CI = 0.05, 0.42, p < 0.001) and constriction (HR = 0.81, 95%CI = 0.41, 1.61, p = 0.55). However, prednisolone increases the hazard of death (HR = 1.58, 95%CI = 1.11, 2.24, p = 0.01). Consistent usage of ART reduces the hazard of composite outcome, death, and constriction but insignificantly increased the hazard of cardiac tamponade. The study offers valuable insights into how prednisolone impact the hazard of different outcomes in patients with TBP and HIV. The findings hold potential clinical significance, particularly in guiding treatment decisions and devising strategies to enhance outcomes in this specific patient group. However, there are concerns about prednisolone potentially increasing the risk of death due to HIV-related death.

Unexpected Difficult Intubation caused by Undiagnosed Laryngeal Tuberculosis in a Patient Requiring Pericardiectomy for Tuberculosis Pericarditis: A Case Report

Airway management is a critical aspect of anesthesia, and difficulties in endotracheal intubation can lead to life threatening complications. While an anticipated difficult intubation can be managed with proper preparation and planning, unexpected difficult intubation can be a challenging situation even to skilled anesthesiologists. We experienced unexpected difficult intubation in a 66-year-old male patient with known tuberculosis pericarditis scheduled for elective pericardiectomy surgery. Multiple intubation attempts were made using various techniques, and successful intubation was achieved with a smaller diameter endotracheal tube. Surgery was uneventful and post-operative evaluation of the airway confirmed laryngeal tuberculosis. This case highlights the importance of vigilance in managing unexpected difficult intubation, especially in patients with a history of tuberculosis or immunosuppressive conditions. Prompt recognition of airway stenosis and appropriate interventions are crucial in securing the airway patency to minimize complications in patients with undiagnosed tuberculosis laryngitis.

Sarcoidosis, tuberculosis, and the clinical dilemma of treating granulomatous inflammation

Sarcoidosis can have a varied presentation, including an overlap with tuberculosis (TB). It can precede or coexist with TB. Certain features such as cavitary consolidation, pleural effusion, and tree-in-bud nodules are highly suggestive of active TB. The perilymphatic distribution of micronodules and discrete lymph nodes are features suggestive of sarcoidosis. Identifying the coexistence of the diseases is essential, as the treatment of either disease is a paradox: immunosuppression in sarcoidosis and antitubercular therapy in TB. There are certain conditions in which immunosuppression is used in TB, e.g., tubercular meningitis, ocular TB, and TB pericarditis. This article aims to provide a better understanding of the clinical dilemma faced during the treatment of granulomatous inflammation and adds to the existing literature regarding the overlap between sarcoidosis and TB.

Effectiveness of Screening in Patients with Rheumatic Disease on Biological Therapy and Risk of Active Tuberculosis

Background: Treatment with biologic therapy has been associated with a high risk of reactivation of latent tuberculosis (TB). Aims and Objectives: The study aimed to access the effectiveness of TB screening recommendations before the initiation of biological therapy and identify the incidence of active TB among these patients. Materials and Methods: A hospital-based retrospective cohort study among rheumatic disease patients on biological therapy in two centers between January 2005 to December 2019 was performed. Data was collected through review of medical records. Results: A total of 365 patients were included over a period of 14 years. Majority had Rheumatoid arthritis (RA) (80%). The mean age was 47.54 (±14.2), 311 (85%) were females with a mean duration of disease 8.45 years (± 6.58). Hundred forty-nine (42.3%) were on steroids. Anti TNFs were prescribed in 213 (58.4%) patients, Non-Anti-TNFs 124 (36.6%) patients, and Jak inhibitors 18 (5%) patients. TB screening was done to all patients except 3 patients (data missing) before commencing biologics. Forty-four (12.1%) patients had latent TB at baseline and all received chemoprophylaxis with isoniazid before starting biologics. Four patients with active TB were identified (one with Behcet’s disease and three with RA). One patient had a reactivation of latent TB and 3 patients developed de novo TB. Two were on rituximab and one each on infliximab and adalimumab. Two cases had pulmonary TB and two others had extrapulmonary TB (pericarditis and brain abscess each). All four patients with active TB were treated with standard anti TB medications. Three had complete resolution of their TB and one died. Conculsion: Baseline screening has been effectively carried out in our cohort as per recommendations. Physicians should be vigilant for symptoms and signs of active TB as not only reactivation of latent TB can occur with patients on biologics but in addition de novo TB can occur specially in endemic areas. Funding: None

Incomplete Pericardial Dissection, Fluid Overload, Delayed Diagnosis And Treatment, And Tuberculosis Pericarditis Are Associated With Low Cardiac Output Syndrome Following Pericardiectomy.

We aimed to investigate risk factors of LCOS following pericardiectomy. This was a retrospective study of patients undergoing pericardiectomy at three hospitals between January 1994 and May 2021. A total of 826 patients were divided into two groups: group with LCOS (N = 126) and group without LCOS (N = 700). The incidence of postoperative LCOS was 15.3%. There were 66 operative deaths (8.0%). Univariable and multivariable analyses showed that factors are associated with LCOS, including postoperative LVEDD (P < 0.001), preoperative LVEDD (P < 0.001), time between symptoms and surgery (P < 0.001), thickness of pericardium (P < 0.001), intubation time (P = 0.002), hospitalized time postoperative (P < 0.001), preoperative central venous pressure (P = 0.016), postoperative central venous pressure (P = 0.034), D0 fluid balance (P = 0.019), D2 fluid balance (P = 0.017), postoperative chest drainage (P < 0.001), surgical duration (P < 0.001), bleeding during operation (P = 0.001), serum creatinine 24h after surgery (P < 0.001), serum creatinine 48h after surgery (P = 0.017), fresh-frozen plasma (P = 0.005), packed red cells (P = 0.006), and tuberculosis pericarditis (P = 0.026). In our study, incomplete pericardial dissection, fluid overload, delayed diagnosis and treatment, and tuberculosis pericarditis are associated with LCOS following pericardiectomy.

Pattern of pericardial calcification determines the mid-term postoperative outcome after pericardiectomy in chronic constrictive pericarditis

Abstract Background/Introduction Although pericardiectomy is an effective treatment of constrictive pericarditis (CP), clinical outcome is not always successful. Pericardial calcification is a unique finding in CP. However, the amount and localization of calcification vary. Computer tomography (CT) can visualize the pericardial calcification with high sensitivity and provide the anatomical assessment. Purpose We investigated that how the pattern and amount of pericardial calcification affect the mid-term postoperative outcome after pericardiectomy in CP. Methods All of the patients who underwent total pericardiectomy in our hospital from 2010 to 2020 were derived from electrical medical records (n=105). Among them, preoperative CT scans (non-gated non-contrast) of 98 patients were available and, thus, 98 consecutive patients were finally analyzed. Medical records were reviewed in a retrospective manner. Cardiovascular event is defined as cardiovascular death or hospitalization associated with a heart failure symptom and all cause event is defined as all events that require admission. CT scan was analyzed by Aquarius Workstation, and the volume and localization pattern of pericalcification were derived. Pericardium calcium score was given as an Agatston score. Results Of 98 patients, 25 (25.5%) patients were hospitalized with heart failure symptom after pericardiectomy. Median follow up duration of patients is 172 weeks. A group with cardiovascular event had higher NYHA grade (P&amp;lt;0.001), lower calcium volume (P=0.004), and lower calcium score (P=0.01). Multivariate cox proportional analysis showed that high ln(calcium score) before pericardiectomy was dependent predictor of cardiovascular event (hazard ratio, 0.90; P=0.04) and all cause event (hazard ratio, 0.91, P=0.04) after pericardiectomy. When we set the cut off value at 7.22, based on ROC curve, there was a significant difference in cardiovascular event between the groups divided by this cutoff value in Kaplan-Meier curve (P=0.002) and multivariate cox proportional analysis (P=0.04). In the subgroup analysis, myocardium invasion and circumferential calcification were more common in the high calcium score group. Idiopathic &amp; tuberculosis pericarditis were more associated with high calcium score group and post-operative pericarditis, other reasons (infection, radiation, etc) were more associated with low calcium group. Conclusion Low burden of pericardial calcification was associated high rate of mid-term clinical event after pericardiectomy CP. Preoperative evaluation of pericardial calcification pattern can be used as predictor of postoperative outcomes. Funding Acknowledgement Type of funding sources: None.

TUBERCULOUS TAMPONADE WITH A TWIST: A CASE OF TB AND COVID-19

TUBERCULOUS TAMPONADE WITH A TWIST: A CASE OF TB AND COVID-19

Role of Corticosteroids in the Treatment of Tuberculosis: An Evidence-based Update

Corticosteroids are often used as an adjunct in the treatment of various forms of tuberculosis (TB) and for the prevention of complications, such as constrictive pericarditis, hydrocephalus, focal neurological deficits, pleural adhesions, and intestinal strictures. Notwithstanding, they have been proven in clinical trials to improve the following outcomes only--death or disability in human immunodeficiency virus (HIV)-seronegative patients with tubercular meningitis and tubercular pericarditis. Despite a lack of specific evidence for efficacy in HIV co-infected patients with tubercular meningitis or pericarditis, corticosteroids are generally recommended in them as well. Corticosteroids significantly decrease the risk of pleural thickening in patients with tubercular pleural effusion; the clinical significance of this finding, however, is unclear. Recently, it has been demonstrated that use of corticosteroids improve the morbidity in HIV co-infected patients with paradoxical TB immune reconstitution inflammatory syndrome (IRIS). However, evidence favouring the use of corticosteroids in other clinical situations is sparse or lacking. Likewise, the biological mechanisms underlying their beneficial effect in TB meningitis and pericarditis remain poorly understood.

A Clinical Case of Tuberculosis Pericarditis Associated with HIV Infection and COVID-19

The article describes a clinical case of tuberculosis pericarditis associated with HIV infection and COVID-19. The patient underwent additional examination due to abnormalities on his X-ray. Large volume of effusion, its lymphocytic nature, bilateral pleural effusion and bilateral infiltration in the upper lobes of both lungs, intrathoracic lymphoadenopathy were indicative tuberculosis etiology of the disease; the diagnosis of tuberculosis was confirmed by morphological tests. COVID-19 was detected post mortem.

Specific Features of Diagnosis, Clinical Course and Treatment of Tuberculosis Pericarditis

The article describes a clinical case of tuberculosis pericarditis in a patient with disseminated pulmonary tuberculosis. X-ray examination of the patient revealed a significant increase in the size of the heart shadow, some fluid in the pericardium up to 1 liter was visualized. The etiology of the disorder was verified by detection of Mycobacterium tuberculosis (MTB) by pericardial fluid culture, and drug sensitivity testing of MTB was performed. Thus an effective treatment regimen was developed, tuberculosis pericarditis and disseminated pulmonary tuberculosis were cured. Echo-CG was used for diagnosis and monitoring of the course of tuberculosis pericarditis.

Analysis of Risk Factors of Early Mortality After Pericardiectomy For Constrictive Pericarditis.

We aimed to investigate risk factors of early mortality following pericardiectomy. This was a retrospective study of patients undergoing pericardiectomy between January 1994 and May 2021 at The People's Hospital of Guangxi Zhuang Autonomous Region, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, and The People's Hospital of Liuzhou City. This study included 826 patients, who were divided into two groups: group with operative deaths (N = 66) and group without operative deaths (N = 760). There were 66 operative deaths (66/826, 8.0%). The causes of operative deaths were multiorgan failure (86/826, 10.4%). Preoperative CVP (P < 0.001), chest drainage (P < 0.001), surgical duration (P < 0.001), fluid balance postoperative day D2 (P < 0.001), and tuberculosis pericarditis (P = 0.001) in group with operative deaths were significantly higher than those in group without operative deaths. Univariate and multivariate analyses showed that factors associated with operative deaths include male (P < 0.001), age (P < 0.001), ICU retention time (P < 0.001), postoperative hospitalization time (P < 0.001), preoperative central venous pressure (P = 0.018), postoperative central venous pressure (P < 0.001), D0 fluid balance (P < 0.001), D2 fluid balance (P < 0.001), postoperative chest drainage (P = 0.029), surgical duration (P = 0.003), serum creatinine baseline (P = 0.002), serum creatinine 24h after surgery (P < 0.001), serum creatinine 48h after surgery (P < 0.001), blood lactate (P < 0.001), and tuberculosis pericarditis (P = 0.033). In our study, incomplete pericardial dissection, fluid overload, and tuberculosis pericarditis are associated with operative deaths following pericardiectomy.

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

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

Pericarditis in contemporary therapeutic clinic: nosological spectrum, approaches to diagnosis and treatment

To analyze the register of pericarditis in a therapeutic clinic, to evaluate their nosological spectrum, to optimize approaches to diagnosis and treatment. For the period 20072018, the register includes 76 patients with the diagnosis of pericarditis (average age 53.115.7 years, 2085 years, 46 female). Patients with hydropericardium were not included in the register. Diagnostic puncture of pericardium was carried out in 5 patients, pleural puncture in 11 patients. Morphological diagnostics included endomyocardial/ intraoperative biopsy of myocardium (n=4/2), thoracoscopic/intraoperative biopsy of pericardium (n=1/6), pleural puncture (n=5), transbronchial (n=1), thoracoscopic biopsy of intrathoracic lymph nodes (n=2), lung (n=1), supraclavicular lymph node biopsy (n=1), salivary gland (n=1), subcutaneous fat and rectum biopsy per amyloid (n=6/1). The genome of cardiotropic viruses, level of anti-heart antibodies, C-reactive protein, antinuclear factor, rheumatoid factor (antibodies to cyclic citrullinized peptide), antibodies to neutrophil cytoplasm were determined, extractable nuclear antigens (ENA), protein immunoelectrophoresis, diaskin test, computed tomography of lungs and heart, cardiac magnetic resonance imaging, oncologic search. The following forms of pericarditis were verified: tuberculosis (14%, including in combination with hypertrophic cardiomyopathy HCM), acute / chronic viral (8%) and infectious immune (38%), including perimyocarditis in 77%, pericarditis associated with mediastinum lymphoma/sarcoma (4%), sarcoidosis (3%), diffuse diseases of connective tissue and vasculitis (systemic lupus erythematosus, rheumatoid arthritis, diseases of Horton, Takayasu, Shegren, Wegener, 12%), leukoclastic vasculitis, Loefflers endomyocarditis, AL-amyloidosis, thrombotic microangiopathy (1% each), HCM (8%), coronary heart disease (constriction after repeated punctures and suppuration; postinfection and immune, 4%), after radiofrequency catheter ablation and valve prosthetics (2%). Tuberculosis was the main causes of constrictive pericarditis (36%). Treatment included steroids (n=39), also in combination with cytostatics (n=12), anti-tuberculosis drugs (n=9), acyclovir/ganclovir (n=14), hydroxychloroquine (n=23), colchicine (n=13), non-steroidal anti-inflammatory drugs (n=21), L-tyroxine (n=5), chemotherapy (n=1). In 36 patients different types of therapy were combined. Treatment results observed in 55 patients. Excellent and stable results were achieved in 82% of them. Pericardiectomy/pericardial resection was successfully performed in 8 patients. Lethality was 13.2% (10 patients) with an average follow-up 9 [2; 29.5] months (up to 10 years). Causes of death were chronic heart failure, surgery for HCM, pulmonary embolism, tumor. During a special examination, the nature of pericarditis was established in 97% of patients. Morphological and cytological diagnostics methods play the leading role. Tuberculosis pericarditis, infectious-immune and pericarditis in systemic diseases prevailed. Infectious immune pericarditis is characterized by small and medium exudate without restriction and accompanying myocarditis. Steroids remain the first line of therapy in most cases. Hydroxychloroquine as well as colchicine can be successfully used in moderate / low activity of immune pericarditis and as a long-term maintenance therapy after steroid stop.

Diagnostic test accuracy of Xpert MTB/RIF for tuberculous pericarditis: a systematic review and meta-analysis.

Introduction: Xpert MTB/RIF is a rapid diagnostic instrument for pulmonary tuberculosis (TB). However, studies reported varied accuracy of Xpert MTB/RIF in detecting Mycobacterium tuberculosis in pericardial effusion. Methods: We performed a systematic review of literature in PubMed, published up to February 1, 2020, according to PRISMA guidelines. We screened cross-sectional studies, observational cohort studies, and randomized control trials that evaluated the accuracy of Xpert MTB/RIF in diagnosing TB pericarditis. Papers with noninterpretable results of sensitivity and specificity, non-English articles, and unpublished studies were excluded. The primary outcomes were the sensitivity and specificity of Xpert MTB/RIF. We conducted a quality assessment using QUADAS-2 to evaluate the quality of the studies. A bivariate model pooled the overall sensitivity, specificity, positive likelihood ratios (PLRs), and negative likelihood ratios (NLRs) of included studies. Results: In total, 581 subjects from nine studies were analyzed in this meta-analysis. Our pooled analysis showed that the overall sensitivity, specificity, PLRs and NLRs of included studies were 0.676 (95% CI: 0.580-0.759), 0.994 (95% CI: 0.919-1.000), 110.11 (95% CI: 7.65-1584.57) and 0.326 (95% CI: 0.246-0.433), respectively. Conclusions: Xpert MTB/RIF had a robust specificity but unsatisfactory sensitivity in diagnosing TB pericarditis. These findings indicated that although positive Xpert MTB/RIF test results might be valuable in swiftly distinguishing the diagnosis of TB pericarditis, negative test results might not be able to rule out TB pericarditis. Registration: PROSPERO CRD42020167480 28/04/2020.

The exudative-constrictive tuberculosis pericarditis diagnosed by toracoscopic biopsy

PurposeTo present the problems and possibilities of diagnostic and treatment in a patient with resistant exudative-constrictive pericarditis. MethodsThe male patient 31 y. was admitted to the clinic due to exudative pericarditis and arthritis of the left knee joint. His medical history periodic febrile fever with a cough, episodes of syncope and atrial fibrillation, treatment with antibiotics and corticosteroids with a temporary effect. ResultsNo data were received for systemic disease, hypothyroidism, tumors. With CT in both lungs, small areas of fibrosis and lymphadenopathy were identified. Pericardial sheets diffusely thickened. EchoCG shows one liter of pericardial fluid with fibrin. All tests for viruses and tuberculosis are negative. Thoracoscopy was performed. Morphological examination showed tuberculosis granulomas with caseous necrosis. The growth of mycobacteria of tuberculosis from sputum was obtained. Therapy included pyrazinamide, ethambutol, levofloxacin, prednisolone 20 mg / day. Ponce's disease regressed. Due to the increase of constriction, subtotal pericardectomy was performed. ConclusionTuberculosis is one of the real causes of pericarditis with massive effusion and an outcome in constriction. The negative results of all laboratory tests for tuberculosis do not exclude the diagnosis. It is necessary to use invasive morphological diagnosis, including thoracoscopic biopsy.

1168Role of 18FDG(fluorodeoxyglucose)-PET (positron emission tomography) for differential diagnosis of pericardial disease

Abstract Background Pericardial disease is frequently associated with systemic diseases. Diagnosis is often troublesome because pericardial fluid does not always give an answer and limited assessment for the acquisition of tissue in effusive-constrictive or constrictive pericarditis. Even after biopsy of pericardium, diagnostic yield is very low without further information for the underlying case. 18FDG-PET can visualize both the inflammation and malignancy through whole body assessment; therefore, it can visualize both pericardium and other organs to provide further insight to the systemic disease. Purpose To assess the role of 18FDG-PET for differential diagnosis of pericardial disease in real clinical practice. Methods Patients who admitted to our pericardial disease clinic who underwent 18FDG-PET for diagnostic methods were derived from electrical medical system database and reviewed. Exclusion criteria were known the advanced stage of malignancy, or already diagnosed from pericardial effusion analysis (positive for malignancy or bacterial culture) by pericardiocentesis. Results Forty patients were finally analyzed. Most common final diagnosis was Idiopathic (n=13, 33%) and tuberculosis (n=12, 28%). Malignancy was diagnosed in 6 patients (15%). Diagnosis of malignancy in all the patients was not confirmed in pericardial effusion. One patient was diagnosed by pericardial biopsy and one by pericardial effusion. Other four were diagnosed by biopsy of other organs. Post-radiation therapy associated pericarditis in two patients, post-operative pericarditis in 5 patients, and transudate, hematoma associated pericarditis, parasite infection in one patient each. Lymph node uptake was found in 28 cases, and four of them was “suggestive malignancy”, 18 was “suggestive benign” and other 6 was “need further evaluation”. All of the patients categorized as “suggestive malignancy” was helped by 18FDG-PET which indicated the optimal biopsy site and 3 of them finally diagnosed as malignancy and one as parasite infection. All of the patients who were categorized as “suggestive benign” were finally diagnosed as a non-malignant disease. Pericardial biopsy was performed in 19 cases (48%) and only 4 were diagnostic. Other 15 specimen showed “chronic inflammation”. Guiding the optimal biopsy site by 18FDG-PET was achieved in 6 patients. 19 cases had normal SUV in the pericardium and 7 patients had very high pericardial SUV more than 10. 6 patients with benign LV pattern was finally diagnosed as tuberculosis pericarditis and one patient with the malignant pattern was finally diagnosed as angiosarcoma Conclusion 18FDG-PET is helpful in the initial assessment of pericardial disease in the aspects of 1) presumptive diagnosis of malignancy in especially in nondiagnostic pericardial effusion or technically risky for pericardiocentesis, 2) Selection of optimal biopsy site with a higher yield of disease, and 3) possibly non-invasive diagnosis of tuberculosis pericarditis. Acknowledgement/Funding None

Sensitivity analysis for the generalized shared-parameter model framework

ABSTRACTIn this paper, we assess the effect of tuberculosis pericarditis treatment (prednisolone) on CD4 count changes over time and draw inferences in the presence of missing data. We accounted for the missing data and performed sensitivity analyses to assess robustness of inferences, from a model that assumes that the data are missing at random, to models that assume that the data are not missing at random. Our sensitivity approaches are within the shared-parameter model framework. We implemented the approach by Creemers and colleagues to the CD4 count data and performed simulation studies to evaluate the performance of this approach. We also assessed the influence of potentially influential subjects, on parameter estimates, via the global influence approach. Our results revealed that inferences from missing at random analysis model are robust to not missing at random models and influential subjects did not overturn the study conclusions about prednisolone effect and missing data mechanism. Prednisolone was found to have no significant effect on CD4 count changes over time and also did not interact with anti-retroviral therapy. The simulation studies produced unbiased estimates of prednisolone effect with lower mean square errors and coverage probabilities approximately equal the nominal coverage probability.