Tuberculous Pericardial Effusion Research Articles

Tuberculous pericardial effusion causing tamponade in a healthy young male:  A diagnostic and therapeutic challenge of a rare manifestation of a fairly frequent disease in Sri Lanka: A Case Report  

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Management and follow-up of abundant tuberculous pericardial effusions experience of a Moroccan care unit

Management and follow-up of abundant tuberculous pericardial effusions experience of a Moroccan care unit

Detection of drug-resistant Mycobacterium tuberculosis in pericardial fluid culture and its correlation with cartridge based nucleic acid amplification test and adenosine deaminase activity

BackgroundPericardial effusion is the accumulation of fluid in the pericardial cavity. In nations with high tuberculosis (TB) load, TB is the most common cause of pericardial effusion. 1–2% of patients with pulmonary TB develop Pericardial TB worldwide. Multi-drug-resistant (MDR) TB, including extrapulmonary TB (EPTB) cases, are rising in number. Adenosine Deaminase (ADA) is an enzyme in lymphocytes and myeloid cells, which has certain immune functions in the body. ADA levels are increased in inflammatory conditions, like pleural, pericardial, or joint effusions, of bacterial etiology, granulomatous conditions, neoplasms, and autoimmune pathologies. TB is the only lymphocytosis involving disease with increased ADA levels. MDR EPTB is rare, but cases are on the rise, and tuberculous pericardial effusion is one such example. Hence, it is important to know the percentage of cases detected by a culture that can be identified by cartridge-based nucleic acid amplification test (CBNAAT), their resistance patterns, and to identify potential markers like ADA, which can help in early identification of cases. The objectives of this study were to identify the Mycobacterium tuberculosis (MTB) bacilli in culture, and correlate them with cartridge-based nucleic acid amplification test (CBNAAT) results and their drug-resistance, in the Pericardial tubercular effusion, and to find if Adenosine Deaminase (ADA) levels can be used as a predictor of the presence of MTB in pericardial fluid. MethodologyWe enrolled 52 patients with moderate to large tuberculous pericardial effusion, based on pericardial fluid analysis, CBNAAT, and culture methods, between January 2021 and December 2021. ResultsThe mean age of the patients was 41.85 + 17.88 years, with a median of 38 years. Males made up 57.7% of the total patients. MTB was detected in 16 (30.8%) patients in the CBNAAT evaluations. 14 (87.5%) of the CBNAAT-positive TB patients were sensitive to Rifampicin, whereas the remaining 2 (12.5%) were resistant to Rifampicin on CBNAAT. MTB was found to be growing in 8 (15.38%) drug sensitivity test cultures. Out of these 8, 6 were sensitive to first-line drugs, whereas 2 were resistant to both Isoniazid and Rifampicin. The presence of cough was found to have a significant difference between CBNAAT-detected MTB positive and negative patients (p = 0.020), whereas an insignificant difference was found for the presence of hypertension, diabetes mellitus, obesity, dyspnea, or fever. There was also an insignificant difference between the number of patients positive for the Tuberculin skin test, between the two groups. ADA was significantly higher in the MTB-detected CBNAAT group (85.91 + 37.60U/L vs 39.78 + 24.31U/L, p = 0.005), whereas the total leukocyte count, lymphocytes, neutrophils, random blood sugar levels, and serum protein levels had no significant difference. The area under the Receiver Operator Curve (CBNAAT positive: dependent variable; ADA: test result variable) was 0.854 (null hypothesis rejected), with a standard error of 0.078. ConclusionsCulture is the gold standard method to diagnose tuberculosis. Detection of MTB on pericardial fluid culture is very uncommon, though in our study, culture came out positive in 16% of patients, and 4% were resistant to rifampicin and isoniazid. Higher ADA levels in pericardial fluid are an indicator of tuberculous pericardial effusion.

PS-R02-3: MASSIVE TUBERCULOUS PERICARDIAL EFFUSION WITHOUT CARDIAC TAMPONADE OR MEDIASTINAL LYMPHADENOPATHY IN AN 88 YEAR OLD MALE: A CASE REPORT

Tuberculosis, although endemic in Asia does not commonly affect the heart and would usually present as constrictive pericarditis. Pericardial involvement heralds an unfavorable prognosis and remains a challenge to clinicians. Cardiac tamponade is common in patients with massive pericardial effusions. In the Philippines, it is the second most common cause of cardiac tamponade as documented in the five-year CAPTIVE Heart Study. Mediastinal lymphadenopathy occurs in all cases and denotes lymphatic spread to the pericardium. We present a rare case of an elderly patient presenting with two month history of dyspnea without fever, weight loss, or chest pain. Echocardiography revealed thickened pericardium with fibrinous strands and massive pericardial effusion of 91 mm without tamponade physiology. CT scan revealed absence of mediastinal or hilar lymphadenopathy. Sputum gene xpert was positive. Anti-tuberculosis regimen was started. Patient also then underwent anterolateral thoracotomy, pleuropericardial window with biopsy. Histopathology revealed chronic inflammatory cells, peripherally located granulomas composed of epitheloid cells and Langhans giant cells confirming tuberculosis as the cause of the pericardial effusion. Large pericardial effusion of more than 20 mm is a predictor to the development of hemodynamic instability and subsequent tamponade. In comparison to 2D Echocardiography findings of the patient with a pericardial effusion measurement of 91 mm, still no tamponade physiology was noted even if the effusion existed for more than a month. Mortality is high even in the absence of cardiac tamponade. Mediastinal lymphadenopathy does not occur in all cases of tuberculous pericardial effusion but is still a possibility as seen in the case. The threshold of chronic massive pericardial effusion in developing into tamponade may be higher than previously noted as documented in the case.

Development and validation a simple scoring system to identify malignant pericardial effusion.

Malignant pericardial effusion (MPE) is a serious complication in patients with advanced malignant tumors, which indicates a poor prognosis. However, its clinical manifestations lack specificity, making it challenging to distinguish MPE from benign pericardial effusion (BPE). The aim of this study was to develop and validate a scoring system based on a nomogram to discriminate MPE from BPE through easy-to-obtain clinical parameters. In this study, the patients with pericardial effusion who underwent diagnostic pericardiocentesis in Taizhou Hospital of Zhejiang Province from February 2013 to December 2021 were retrospectively analyzed. The eligible patients were divided into a training group (n = 161) and a validation group (n = 66) according to the admission time. The nomogram model was established using the meaningful indicators screened by the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression. Then, a new scoring system was constructed based on this nomogram model. The new scoring system included loss of weight (3 points), no fever (4 points), mediastinal lymph node enlargement (2 points), pleural effusion (6 points), effusion adenosine deaminase (ADA≦18U/L) (5 points), effusion lactate dehydrogenase (LDH>1033U/L) (7 points), and effusion carcinoembryonic antigen (CEA>4.9g/mL) (10 points). With the optimal cut-off value was 16 points, the area under the curve (AUC), specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) for identifying MPE were 0.974, 95.1%, 91.0%, 85.6%, 96.8%, 10.56 and 0.05, respectively, in the training set and 0.950, 83.3%, 95.2%, 90.9%, 90.9%, 17.50, and 0.18, respectively, in the validation set. The scoring system also showed good diagnostic accuracy in differentiating MPE caused by lung cancer from tuberculous pericardial effusion (TPE) and MPE including atypical cell from BPE. The new scoring system based on seven easily available variables has good diagnostic value in distinguishing MPE from BPE.

A rare case of adolescent tuberculous pericardial effusion: a case report

Tuberculous pericarditis (TBP) is a rare case of extrapulmonary TB (EPTB) especially in the developed countries. This may cause serious and deadly impact if not diagnosed and treated properly. A-15-year-old girl was admitted with tightness of breath, weight loss, a productive cough and fatigue. Severe malnutrition, bronchial rales and anemia are present in patient. Chest x-ray showed pleural effusion with cardiomegaly. On three days later, Thoracic multi-slice spiral (MSCT) confirmed pericardial effusion, following pericardiocentesis on the fifth day. Tuberculous was confirmed by analysis of pericardial fluid. This patient was diagnosed as tuberculosis pericardial effusion showed complete recovery after pericardiocentesis and anti-tuberculosis drugs administration. Tuberculous is an endemic disease and its extrapulmonary forms should be included as a differential diagnosis. Early and adequate treatment decreases the risk of developing into a potentially fatal disease.

Corticosteroids in tuberculous pericarditis whit severe pericardial effusion to avoid constriction: a retrospective study in HIV-negative population

Abstract The role of corticosteroids in the treatment of tuberculous aetiology pericarditis without human immunodeficiency virus (HIV) is not well defined. Is unclear if associating corticoids to regular antibiotic therapy for tuberculosis, can prevent the progression of a severe pericardial effusion to constrictive pericarditis. Despite that, in countries where tuberculosis is an endemic disease and mostly it's not related to HIV, the use of corticosteroids is a common practice, as a part of a strategy to avoid progression of a severe pericardial effusion to a constrictive pericarditis. Our aim is to describe the clinical course of the patients with severe pericardial effusion of tuberculous aetiology and no echocardiographic sings of constriction, distinguishing those who used corticosteroids from those who didn't. We conducted a retrospective study, analyzing the clinical files of 40 patients treated in one hospital in a 5 years period (2016–2021). All of these patients were diagnosed whit severe pericardial effusion of tuberculous aetiology and no signs of constrictive pericarditis, they all finished their specific antibiotic treatment protocol according national guidelines and had at least 2 years of clinical follow from the time of the diagnosis. We found that the mean age was 54 years, 55% were men and 45% women. The mean follow up was 2.6 years. In all patients pericardial drainage was preformed, 60.5% using closed pericardiocentesis and 39.5% using open surgical techniques. 22 patients (55%) received prednisone that was initiated whit a dose of 1mg/kg daily that was reduced weekly in order to complete a 2 month cycle. The other 18 patients (45%) didn't received corticosteroids. In the prednisone group, 3 patients develop constrictive pericarditis during the time of follow up (13.6% of the prednisone group) while 7 patients of the non-corticosteroids group (38.8%) develop constrictive pericarditis. These retrospective study shows that there is a potential reduction in the progression to constrictive pericarditis whit the use of prednisone in HIV negative patients whit severe pericardial effusion of tuberculous aetiology, we need to perform prospective, controlled, blind and multicenter studies, designed to evidence the real effect of these strategy. Funding Acknowledgement Type of funding sources: None. Cases of contriction in both groups

Emergency Department Presentation and Outcome of Children With Cyanotic Congenital Heart Diseases.

ObjectiveThis study aimed to assess the outcome and see the spectrum of presenting symptoms of children with cyanotic congenital heart diseases (CHDs) admitted through the emergency department in Lady Reading Hospital (LRH) in Peshawar, Pakistan.Materials and methodsThis cross-sectional study included 104 children with cyanotic CHD admitted through the emergency department in the pediatric cardiology unit of LRH from February 2019 to January 2020. Diagnosis of cyanotic CHD was confirmed through two-dimensional echocardiography. Patients were treated according to standard protocols for their presenting symptoms. The data were analyzed using Statistical Package for the Social Sciences (SPSS), version 20.0 (IBM Corp., Armonk, NY) and frequencies were expressed as percentages.ResultsThe study included 65 male cases (62.5%) and 39 female cases (37.5%), and participant ages ranged from 10 days to 15 years (mean, 2.7 ± 3.4 years). Of 104 patients, 70 presented with cyanotic spells (84.5%), 53 with fever (10.7%), 28 with respiratory distress (26.5%), 11 with loose stools (10.5%), 10 with hemiplegia (9.6%), and eight with seizures (7.6%). Pneumonia was a precipitating factor in 13 patients (12.5%), infective endocarditis in 12 patients (11%), gastroenteritis in 11 (11%), brain abscess and cerebrovascular accidents in seven patients each (6% each), meningitis in six patients (6%), and tuberculous pericardial effusion in one patient (<1%). The primary CHD was tetralogy of Fallot (TOF) in 52 patients, tricuspid atresia in 14 patients, pulmonary atresia in 13 patients, double outlet right ventricle in 10 patients, transposition of great arteries (TGA) in seven patients, and total anomalous pulmonary venous return (TAPVR), truncus arteriosus, congenitally corrected TGA, and critical pulmonary stenosis in two patients each. Twenty-six patients received treatment of the acute problem and instructions for follow-up monitoring. Twelve patients died during their hospital stay, and three left against medical advice. Fifteen patients received patent ductus arteriosus stenting, and six received right ventricular outflow tract stenting. One patient received a Blalock-Taussig (BT) shunt stent, and one received a left pulmonary artery stent. Two patients received a balloon pulmonary valvotomy, and one received pericardial effusion drainage. Eleven patients received surgical correction of TOF, 11 received surgical correction for BT shunt, four received surgical correction for brain abscess drainage, and two received TAPVR repair.ConclusionTOF was the most common cyanotic heart disease in our study. Cyanotic spells or increased cyanosis was the most common presenting concern. Cyanotic CHDs present with variable extracardiac signs and symptoms in emergencies. Appropriate assessment, immediate management of the acute problem, and timely intervention or surgical management result in good outcomes.

Melioidosis complicated with pericardial effusion - An emerging disease with a rare presentation

Melioidosis, caused by a non-fermenting gram negative bacilli, can mimic a variety of diseases due to its diverse clinical presentation. The incidence of cardiac involvement in melioidosis is less than 1%. We report a rare case of melioidosis in a 65 year old male with chronic kidney disease who presented with fever and pericardial effusion which was misdiagnosed and treated as tuberculous pericardial effusion. Later, on isolation of from paired blood culture samples, pericardial fluid and also from pleural fluid confirmed the diagnosis of disseminated melioidosis. The patient was treated with intravenous ceftazidime after which clinical improvement was observed. Cardiac melioidosis should always be considered in the differential diagnosis of tuberculous pericardial effusion and it should be ruled out before the start of anti-tubercular treatment. This will prevent unnecessary exposure to anti-tubercular drugs and also aids to start early treatment for melioidosis thereby reducing the mortality.

Right-Sided Constrictive Pericarditis: A Rare Variant of an Uncommon Disease

Constrictive pericarditis (CP) is characterized by thick pericardial fibrosis and calcification that causes progressively impaired diastolic filling of the heart with associated symptoms of heart failure. Rarely, it can also present as localized CP and depending on the CP location, clinical presentation can be variable, including compression and obstruction of right ventricular inflow tract, coronary obstruction, or pulmonary stenosis. We report a rare case of isolated constriction of the right side of the heart due to loculated tuberculous pericardial effusion.

Subxiphoid Tube Pericardiostomy in the Management of Pericardial Effusion: Our Experience

Introduction – There is minimal amount of fluid within the two layers of the pericardium. This serves to lubricate the layers preventing friction. Various disease processes can lead to increase in the amount of this fluid which cause haemodynamic compromise these patients. Various methods have been used to drain this fluid. We report our experience with subxiphoid tube pericardiotomy in the drainage of pericardial effusion. Material and Method – we reviewed case files of 30 patients that presented to us with pericardial effusion over a six-year period. Results - There were 19 males (63.3%) and 11 females (36.7%). Age range is between 2 yrs and 65 years with a mean of 27.3 yrs. Adult age group accounted for 25 (83.3%) while paediatric age group was 5 (16.7%). Predominant symptom was dyspnea and all patients had subxiphoid tube pericardiostomy for drainage. Majority of our patients (80%) had tuberculosis as the cause of their effusion. Mortality was 3 (10%) following the drainage but cause of death was progression of their disease. The was recurrence in one patient who had malignant effusion and was subsequently treated with pericardial window but later lost to follow up. Conclusion - Subxiphoid tube pericardiostomy still remains the main stay in the management of massive tuberculous pericardial effusion in our environment as it provides the opportunity to drain the fluid and take adequate fluid samples and tissue for diagnosis. Recurrence rate is also low.

Tuberculous Pericardial Effusions in Children.

Current data on tuberculous pericardial effusion in children are limited. In this study, the cases of 30 children with tuberculous pericardial effusion were reviewed retrospectively. The prevalence of human immunodeficiency virus and of culture-confirmed tuberculosis was high. Chest radiography provided lower diagnostic sensitivity than sonography but detected all large and complicated effusions. Outcomes were generally good, and residual complications were mainly due to comorbidity.

Echocardiographic Findings of Tuberculous Pericardial Effusion in Early Stage of Chronic Kidney Disease

Echocardiographic Findings of Tuberculous Pericardial Effusion in Early Stage of Chronic Kidney Disease

Anasarca as the Initial Manifestation of Tuberculous Pericarditis in a Child

AbstractPericarditis is a rare manifestation of tuberculosis in children. The usual clinical features include fever, cough, tachypnea, chest pain, and pedal edema. Very rarely, generalized edema may occur as a presenting feature. We describe a 10-year-old boy, who presented with anasarca and had received treatment with corticosteroids for a mistaken diagnosis of nephrotic syndrome and was subsequently diagnosed with tuberculous pericardial effusion. The rarity of manifestations and the difficulties encountered to diagnose tuberculous pericarditis prompted us to report this case. The report may serve to sensitize pediatricians to consider systematic investigations to reach the diagnosis in children presenting with anasarca and avoid the empiric use of steroids in anasarca.

The spectrum of heart disease in adults in Malawi: A review of the literature with reference to the importance of echocardiography as a diagnostic modality.

Malawi, like many developing countries, is in a state of health transition from predominately infectious diseases to predominately noncommunicable diseases (NCDs).1–3 This transition has caused many countries to have a “double burden” of disease, with high levels of both communicable and noncommunicable pathologies.4,5 The transition has coincided with increasing affluence and life expectancy among Malawians. Between 2003 and 2013, life expectancy in Malawi has increased from 37 to 53 years,6 with an adjusted life expectancy of 77 years for Malawians who survive to age 60.7 Cardiac diseases related to infection may present at any age, but those related to NCDs predominate in older age groups. The spectrum of heart disease can provide an indicator of the health transition from infectious to non-infectious diseases. Echocardiography is a noninvasive modality for gaining both structural and functional information about the heart. Echocardiography can be used to identify infection-related pathology, such as valvular heart disease following rheumatic fever or tuberculous pericardial effusion,8 and noncommunicable pathologies such as hypertensive heart disease or cor pulmonale. The information gained can lead to life-saving changes in management. This review will describe the spectrum of adult cardiac disease in Malawi, including changes over time, especially the impact of the HIV epidemic and the health transition from communicable to noncommunicable diseases. Selected studies from the sub-Saharan region will be reviewed to illustrate the usefulness of echocardiography in diagnosing heart disease when other investigations are not available.

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Redefining Effusive-Constrictive Pericarditis with Echocardiography.

BackgroundEffusive-constrictive pericarditis (ECP) is traditionally diagnosed by using the expensive and invasive technique of direct pressure measurements in the pericardial space and the right atrium. The aim of this study was to assess the diagnostic role of echocardiography in tuberculous ECP.MethodsIntrapericardial and right atrial pressures were measured pre- and post-pericardiocentesis, and right ventricular and left ventricular pressures were measured post-pericardiocentesis in patients with tuberculous pericardial effusions. Echocardiography was performed post-pericardiocentesis. Traditional, pressure-based diagnostic criteria were compared with post-pericardiocentesis systolic discordance and echocardiographic evidence of constriction.ResultsThirty-two patients with tuberculous pericardial disease were included. Sixteen had ventricular discordance (invasively measured), 16 had ECP as measured by intrapericardial and right atrial invasive pressure measurements and 17 had ECP determined echocardiographically. The sensitivity and specificity of pressure-guided measurements (compared with discordance) for the diagnosis of ECP were both 56%. The positive and negative predictive values were both 56%. The sensitivity of echocardiography (compared with discordance) for the diagnosis of ECP was 81% and the specificity 75%, while the positive and the negative predictive values were 76% and 80%, respectively.ConclusionEchocardiography shows a better diagnostic performance than invasive, pressure-based measurements for the diagnosis of ECP when both these techniques are compared with the gold standard of invasively measured systolic discordance.

The Effects of Angiotensin Converting Enzyme Inhibitors (ACE-I) on Human N-Acetyl-Seryl-Aspartyl-Lysyl-Proline (Ac-SDKP) Levels: A Systematic Review and Meta-Analysis.

BackgroundTuberculous pericardial effusion is a pro-fibrotic condition that is complicated by constrictive pericarditis in 4% to 8% of cases. N-acetyl-seryl-aspartyl-lysyl-proline (Ac-SDKP) is a ubiquitous tetrapeptide with anti-fibrotic properties that is low in tuberculous pericardial effusion, thus providing a potential mechanism for the heightened fibrotic state. Angiotensin-converting enzyme inhibitors (ACE-I), which increase Ac-SDKP levels with anti-fibrotic effects in animal models, are candidate drugs for preventing constrictive pericarditis if they can be shown to have similar effects on Ac-SDKP and fibrosis in human tissues.ObjectiveTo systematically review the effects of ACE-Is on Ac-SDKP levels in human tissues.MethodsWe searched five electronic databases (1996 to 2014) and conference abstracts with no language restrictions. Two reviewers independently selected studies, extracted data and assessed methodological quality. The protocol was registered in PROSPERO.ResultsFour studies with a total of 206 participants met the inclusion criteria. Three studies (106 participants) assessed the change in plasma levels of Ac-SDKP following ACE-I administration in healthy humans. The administration of an ACE-I was associated with an increase in Ac-SDKP levels (mean difference (MD) 5.07 pmol/ml (95% confidence intervals (CI) 0.64 pmol/ml to 9.51 pmol/ml)). Two studies with 100 participants further assessed the change in Ac-SDKP level in humans with renal failure using ACE-I. The administration of an ACE-I was associated with a significant increase in Ac-SDKP levels (MD 8.94 pmol/ml; 95% CI 2.55 to 15.33; I2 = 44%).ConclusionACE-I increased Ac-SDKP levels in human plasma. These findings provide the rationale for testing the impact of ACE-I on Ac-SDKP levels and fibrosis in tuberculous pericarditis.

Genexpert technology: A new ray of hope for the diagnosis of tuberculour pericardial effusion

Tuberculous pericardial effusion is a well-known complication of tuberculosis (TB). However, the greatest challenge in front of clinicians is its diagnosis as the conventional methods lack the required sensitivity and specificity of detection. The emergence of drug resistance and co-infections such as human immunodeficiency virus further complicates the situation making it difficult to diagnose such cases. GeneXpert technology is a major breakthrough in the field of TB diagnosis and has opened newer avenues for many new molecular tests to be launched in the future. The World Health Organization endorsed this technology in 2010 for rapid and simultaneous detection of Mycobacterium tuberculosis (MTB) and rifampicin (RIF) resistance. GeneXpert-MTB/RIF assay was highly recommended as an initial diagnostic platform in high burden countries for early and quick detection of TB cases. Until date, very few studies have evaluated the performance of this brilliant assay in pericardial effusion cases, thus, more studies are required to address the unanswered questions left so far. Our review attempts to recapitulate the achievements, the potential impacts and the prospective use of this novel technology in early diagnosis of TB, especially focussing pericardial effusion cases.

Myopericarditis in tuberculous pericardial effusion: prevalence, predictors and outcome

ObjectiveThe prevalence, predictors and outcome of myopericarditis in patients with tuberculous (TB) pericarditis are unknown.MethodsEighty-one patients (mean age±SD, 36.1±13.3 years; 54 (66.7%) men; 58 (71.6%) HIV seropositive) with TB pericarditis...