Tuberculous Pericarditis Research Articles

Chronic mitral-aortic fibrosa pseudoaneurysm after aortic valve replacement

A 67-year-old male with previous tuberculous pericarditis with pericardiectomy and two prior aortic valve replacements was found to have a posterior aortic pseudoaneurysm in a transoesophageal echocardiogram. A computed tomography was ordered (Figs 1 and 2 and Supplementary Video 1). Due to the complicated anatomy of the aneurysm and the extensive pericardial calcification, the risks of a fourth surgery were considered high, and the patient was discharged with close clinical follow-up. Supplementary material (Video 1) is available at EJCTS online.

Chylous ascites and chylothorax due to constrictive pericarditis in a patient infected with HIV: a case report

IntroductionChylothorax and chylous ascites are uncommon and usually associated with trauma or neoplasms. To the best of our knowledge, constrictive pericarditis leading to chylothorax and chylous ascites in a person infected with HIV has never previously been described.Case presentationA 39-year-old Thai man was referred to our institute with progressive dyspnea, edema and abdominal distension. His medical history included HIV infection and pulmonary tuberculosis that was complicated by tuberculous pericarditis and cardiac tamponade. Upon further investigation, we found constrictive pericarditis, chylothorax and chylous ascites. A pericardiectomy was performed which resulted in gradual resolution of the ascites and chylous effusion.ConclusionsAlthough constrictive pericarditis is an exceptionally rare cause of chylothorax and chylous ascites, it should nonetheless be considered in the differential diagnosis as a potentially reversible cause.

The quality of life of a 12-year-old malnourished girl with tuberculous pericarditis

The quality of life of a 12-year-old malnourished girl with tuberculous pericarditis

Tuberculous pericarditis with and without HIV

The human immunodeficiency virus (HIV) has altered the epidemiology, clinical manifestations, treatment considerations and natural history of tuberculous (TB) pericarditis with significant implications for clinicians. The caseload of TB pericarditis has risen sharply in TB endemic areas of the world where co-infection with HIV is common. Furthermore, TB is the cause in greater than 85% of cases of pericardial effusion in HIV-infected cohorts. In the absence of HIV, the morbidity of TB pericarditis is primarily related to the ferocity of the immune response to TB antigens within the pericardium. In patients with HIV, because TB pericarditis more often occurs as part of a disseminated process, the infection itself has a greater impact on the morbidity and mortality. HIV-associated TB pericarditis is a more aggressive disease with a greater degree of myocardial involvement. Patients have larger pericardial effusions with more frequent hemodynamic compromise and more significant ST segment changes in the electrocardiogram. HIV alters the natural history and outcomes of TB pericarditis. Immunocompromised participants appear less likely to develop constrictive pericarditis and have a significantly higher mortality compared with their immunocompetent counterparts. Finally co-infection with HIV has resulted in a number of areas of uncertainty. The mechanisms of myocardial dysfunction are unclear, new methods of improving the yield of TB culture and establishing a rapid bacterial diagnosis remain a major challenge, the optimal duration of anti-TB therapy has yet to be established, and the role of corticosteroids has yet to be resolved.

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.

Women's cardiovascular health in Africa

The predominant pattern of cardiovascular diseases in sub-Saharan Africa is that of poverty-related conditions (rheumatic heart valve disease, untreated congenital heart disease, tuberculous pericarditis) and diseases of unclear aetiology with...

The prevalence and outcome of effusive constrictive pericarditis : a systematic review of the literature

There is sparse information on the epidemiology of effusive constrictive pericarditis (ECP). The objective of this article was to review and summarise the literature on the prevalence and outcome of ECP, and identify gaps for further research. The prevalence of ECP ranged from 2.4 to 14.8%, with a weighted average of 4.5% [95% confidence interval (CI) 2.2-7.5%]. Sixty-five per cent (95% CI: 43-82%) of patients required pericardiectomy regardless of the aetiology. The combined death rate across the studies was 22% (95(CI: 4-50%). The prevalence of ECP is low in non-tuberculous pericarditis, while pericardiectomy rates are high and mortality is variable. In this review, of 10 patients identified with tuberculous ECP, only one presumed case had a definite diagnosis of ECP. Appropriate studies are needed to determine the epidemiology of ECP in tuberculous pericarditis, which is one of the leading causes of pericardial disease in the world.

Sudden Cardiac Arrest Caused by Tuberculous Pericarditis with Hemorrhagic Pericardial Effusion

As tuberculosis still exists in Japan, tuberculous pericarditis is a major health issue. Tuberculous pericarditis is difficult to diagnose and leads to poor outcomes when left untreated. We herein report the case of a patient who was admitted to the hospital after undergoing resuscitation for cardiopulmonary arrest. Mycobacterium tuberculosis was detected in his hemorrhagic pericardial fluid and tuberculous pericarditis was diagnosed. The administration of antituberculous medication resulted in marked improvements. A diagnosis of tuberculous pericarditis, in addition to other causes such as malignant tumors, should therefore be considered in the differential diagnosis for cases presenting with hemorrhagic pericardial effusion, even in those involving sudden cardiac arrest.

Appropriateness of Adenosine Deaminase-Guided Management for Patients with Pericardial Effusion

Background/Aims: The prognostic impact of empirical anti-tuberculous management according to adenosine deaminase (ADA) levels in patients exhibiting pericardial effusion (PE) has not been established. We evaluated the appropriateness of ADA-guided anti-tuberculous medication for patients with PE. Methods: From 2001 to 2010, 47 patients with PE and who were diagnosed with either tuberculous pericarditis (TbP) or idiopathic pericarditis (IP) were enrolled. The diagnosis of definite TbP was made by the presence of Tb bacilli or caseous granuloma in pericardial tissue or effusion. The diagnosis of probable TbP was made by the presence of one or more of the following: (1) elevated ADA (≥ 40 IU/L) in pericardial fluid, (2) positive Tb interferon test, or (3) extracardiac presence of Tb. All clinical information was collected by medical record review and telephone contact. Results: Among the 47 patients with PE, 12 were diagnosed with definite TbP; 17, with probable TbP; and 18, with IP. The mean ADA level was significantly higher in patients with definite TbP than in patients with IP (74.97 ± 36.79 vs. 20.14 ± 7.39 IU/L; p < 0.001). The optimal ADA cutoff value for diagnosis of definite TbP was 64 IU/L. The median follow-up time was 12.1 months (range, 0.17-100 months). In patients with low levels of ADA (< 40 IU/L), the incidence of death or recurrence did not different between patients who were prescribed anti-tuberculous medication and those who were not. Conclusions: The ADA level in pericardial fluid was useful for making a rapid diagnosis of tuberculous pericarditis. Even in tuberculosis-endemic areas, patients with ADA < 40 IU/L may have a good prognosis without empirical anti-tuberculous treatment. (Korean J Med 2012;82:441-448)

The Ratio Between the Percentage of Lymphocytes and Glucose Levels in Pericardial Fluid as a Method to Diagnose Tuberculous Pericarditis

Background/Aims: Adenosine deaminase (ADA) is a valuable biochemical marker for pericardial effusion (PE) and may be useful for diagnosing tuberculous pericarditis (TPE) in patients with PE. However, no definite cut-off or borderline values for ADA currently exist to distinguish TPE from other PE etiologies. In this study, we identified other useful parameters and characterized their relationship with ADA as a method for diagnosing TPE. Methods: From June 2004 to November 2011, 42 patients underwent pericardiocentesis due to moderate or severe PE, as confirmed by echocardiography or chest computed tomography (CT). Patients were subdivided into TPE and non-TPE (NTPE) groups. We analyzed ADA (p) (the pericardial ADA) and %Lymph (p)/Glucose (p) (the ratio between the percentage of lymphocytes and glucose levels in PE). Results: We defined the cut-off value of ADA (p) as 48.5 IU/L, and that of %Lymph (p)/Glucose (p) as 0.678%·dL/mg. In a multivariate logistic regression analysis, an odds ratio (OR) of 44.24 and a 95% confidence interval (CI) of 2.85-686.97 were observed in patients with an ADA (p) ≥ 48.5 IU/L (p = 0.023). An OR of 20.39 and a 95% CI of 1.06-392.93 were observed in patients with a %Lymph (p)/Glucose (p) ≥ 0.678%·dL/mg (p = 0.046). The combination of ADA (p) and %Lymph (p)/Glucose (p) had a higher positive predictive value (PPV, 80.0%) and specificity (Sp, 93.8%) than either ADA (p) (PPV, 47.4%; Sp, 68.8%) or %Lymph (p)/Glucose (p) (PPV, 69.2%; Sp, 87.5%) alone. Conclusions: %Lymph (p)/Glucose (p) is a useful parameter for distinguishing TPE from other pericardial diseases if combined with an ADA (p) ≥ 48.5 IU/L. (Korean J Med 2012;83:458-467)

Tuberculous Pericarditis Presenting as Multiple Free Floating Masses in Pericardial Effusion

Pericarditis is a rare manifestation of tuberculosis (Tb) in children. A 14-yr-old Korean boy presented with cardiac tamponade during treatment of pulmonary tuberculosis. He developed worsening anemia and persistent fever in spite of anti-tuberculosis medications. Echocardiography found free floating multiple discoid masses in the pericardial effusion. The masses and exudates were removed by pericardiostomy. The masses were composed of pink, amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes with numerous acid-fast bacilli, which were confirmed as Mycobacterium species by polymerase chain reaction. The persistent fever and anemia were controlled after pericardiostomy. This is the report of a unique manifestation of Tb pericarditis as free floating masses in the effusion with impending tamponade.

A difficult diagnostic case of tuberculous pericarditis mixed infection with streptococcus viridans

A difficult diagnostic case of tuberculous pericarditis mixed infection with streptococcus viridans

結核性心膜炎の治療中に発症した急性Ａ型大動脈解離の１例

症例は69歳，女性．10代のときに腎結核で右腎摘出の既往があった．2011年，1月初旬から微熱・食欲不振があり，呼吸苦が出現したため当院へ紹介入院となった．心エコーと単純CTで上行大動脈の拡大と心嚢液貯留を認め，心タンポナーデと診断し心嚢穿刺を行った．心嚢液の塗抹培養およびpolymerase chain reaction（PCR）で結核菌は検出されなかったが，adnosine deaminase（ADA）活性が高値であったため結核性心膜炎として4剤併用抗結核療法を開始した．しかし加療中の第32病日，夜間突然の背部痛が出現した．急性A型大動脈解離と診断し，緊急手術にて大動脈基部および上行置換術を施行した．病理検査の結果，上行大動脈外膜にLanghans型巨細胞を伴う肉芽腫性炎症所見が認められた．術後経過は良好で4剤併用療法を2カ月間施行し，現在リファンピシン，イソニアジドの2剤併用療法を継続中である．術後70日以上経過中で，グラフト感染などは合併していないが注意深いフォローが必要である．

Intracardiac left atrial tuberculoma in an eleven-month-old infant: case report

BackgroundCardiac tuberculosis is rare and usually manifests as tuberculous pericarditis. Involvement of other part of the heart is unusual and descriptions in the pediatric literature are confined to few case reports regarding mainly myocardial tuberculosis.Case presentationWe describe a case of pulmonary miliary tuberculosis associated with intracardiac left atrial tuberculoma in an immunocompetent eleven-month-old infant successfully treated with surgery and antituberculous therapy.ConclusionAlthough unusual, involvement of endocardium in disseminated tuberculosis should be kept in mind.

Tuberculous pericarditis: a diagnostic quandary

Tuberculous pericarditis is uncommon in the Western world, and can prove a diagnostic quandary in that confirmation of the diagnosis and culture of mycobacteria can be difficult. We present a case of tuberculous pericarditis where endobronchial ultrasound-guided transbronchial needle biopsy of a pathological lymph node provided the diagnosis after other methods of investigation had proved futile.

ORAL PRESENTATION

ORAL PRESENTATION

Tuberculous Pericarditis

Tuberculous pericarditis, caused by Mycobacterium Tuberculosis, is found in approximately 1% of all autopsied cases of tuberculosis (TB) and in 1% to 2% of instances of pulmonary TB.1&nbsp;Pericardial involvement usually develops by the retrograde lymphatic spread of Mycobacterium Tuberculosis from peritrachial, peribronchial or mediastinal lymph nodes or by hematogenous spread from primary tuberculous infection.2, 3&nbsp;Tuberculous pericarditis presents clinically in 3 forms, consisting of pericardial effusion, constrictive pericarditis and a combination of effusion and constriction.4

Risk of Constrictive Pericarditis After Acute Pericarditis

Constrictive pericarditis (CP) is considered a rare, dreaded possible complication of acute pericarditis. Nevertheless, there is a lack of prospective studies that have evaluated the specific risk according to different etiologies. The aim of this study is to evaluate the risk of CP after acute pericarditis in a prospective cohort study with long-term follow-up. From January 2000 to December 2008, 500 consecutive cases with a first episode of acute pericarditis (age, 51±16 years; 270 men) were prospectively studied to evaluate the evolution toward CP. Etiologies were viral/idiopathic in 416 cases (83.2%), connective tissue disease/pericardial injury syndromes in 36 cases (7.2%), neoplastic pericarditis in 25 cases (5.0%), tuberculosis in 20 cases (4.0%), and purulent in 3 cases (0.6%). During a median follow-up of 72 months (range, 24 to 120 months), CP developed in 9 of 500 patients (1.8%): 2 of 416 patients with idiopathic/viral pericarditis (0.48%) versus 7 of 84 patients with a nonviral/nonidiopathic etiology (8.3%). The incidence rate of CP was 0.76 cases per 1000 person-years for idiopathic/viral pericarditis, 4.40 cases per 1000 person-years for connective tissue disease/pericardial injury syndrome, 6.33 cases per 1000 person-years for neoplastic pericarditis, 31.65 cases for 1000 person-years for tuberculous pericarditis, and 52.74 cases per 1000 person-years for purulent pericarditis. CP is a relatively rare complication of viral or idiopathic acute pericarditis (<0.5%) but, in contrast, is relatively frequent for specific etiologies, especially bacterial.

Recurrent, Massive Kaposi’s Sarcoma Pericardial Effusion Presenting without Cutaneous Lesions in an HIV Infected Adult: A Case Report.

In this report we describe the case of a 22-year-old female who presented to our hospital with a 2 week history of chest tightness and easy fatigability. Examination and chest ultrasound revealed a massive pericardial effusion with evidence of tamponade. A rapid test for HIV was positive. Diagnostic and therapeutic pericardiocentesis was performed with good clinical response and revealed serosanguinous, exudative fluid. According to national guidelines, the patient was empirically treated for tuberculous pericarditis. Recurrence of the pericardial effusion occurred after 2 weeks and the cardiothoracic surgeons were consulted. Several days later, the patient was taken to the operating theatre and a pericardial window was performed with resultant drainage of over 5 litres of pericardial fluid. Visualization of the pericardium revealed a purple, multinodular mass of about 4x6cm on the epicardium consistent with Kaposi's sarcoma of the pericardium. Five litres of blood stained fluid were drained. Anti-tuberculosis treatment was stopped and the patient was referred to the oncology unit. The patient was started on antiretroviral treatment and Vincristine chemotherapy and the pericardial effusion resolved completely after 6 cycles of chemotherapy. Kaposi sarcoma should be considered as differential diagnosis in HIV/AIDS patient presenting with massive pericardial effusion.

Current Concepts in the Management of Tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.