acute primary tuberculous pericarditis
TRANSCRIPT
Acute Primary Tuberculous Pericarditis
Hsien-Kuo Chin, Yee-Phoung Chang and Chia-Shen Chao
Acute primary tuberculous (TB) pericarditis is a rare but life-threatening condition. It may lead to diastolic heart
failure in constrictive pericarditis. A 77-year-old man suffered from exertional dyspnea for 3 weeks. He had
received percutaneous transluminal coronary angioplasty (PTCA) with stent for left anterior descending artery
lesion 3 weeks prior to this admission. As dyspnea on exertion persisted, he was admitted to our hospital for possible
coronary arterial bypass grafting. No significant in-stent restenosis was found during recatheterization. Meanwhile,
bilateral pleural effusions were found, but they were negative for TB cultures and polymerase chain reaction (PCR).
Thickening of pericardium with large amount of pericardial effusion was noted during echocardiographic examination
3 weeks after admission. Emergent pericardiotomy was done for cardiac tamponade and biopsy. Acute primary TB
pericarditis was diagnosed and antituberculous chemotherapy plus adjuvant corticosteroid treatment were given.
The patient was discharged 2 weeks later in fair condition. Unfortunately, one month later he was readmitted due to
constrictive pericarditis. Pericardiectomy was done. After a full course of anti-TB therapy for 9 months, the patient
kept well after follow-up for one year.
Key Words: Cardiac tamponade � Corticosteroid � Pericardiectomy � Primary tuberculous pericarditis
INTRODUCTION
Acute pericarditis1 (< 3 months) is dry, fibrinous or
effusive, independent of its etiology. Most cases of acute
pericarditis are viral or idiopathic. Other causes are un-
common, including bacterial infection, tuberculosis, ur-
emic pericarditis, myocardial infarction, previous cardiac
surgery, complication after radiotherapy, cancer, and in-
flammatory diseases, etc. Each year, there are approxi-
mately 9 million new cases of tuberculosis worldwide,
and 3 million die from the disease. Tuberculosis (TB) is
a serious problem in developing countries, which ac-
count for 95% of worldwide TB cases, and 99% of
worldwide TB mortality. TB has not been on the list of
the leading causes of death in Taiwan since 1985. How-
ever, the incidence of TB in Taiwan remains high. Ac-
cording to a report from the Center for Disease Control
of Taiwan in 2002, the incidence and mortality rate of
TB were 74.6 and 5.68 per 100,000 population, respec-
tively.2 Pulmonary involvement accounted for 77.8% of
cases, with TB and isolated extra-pulmonary involve-
ment only accounting for 22%.3 Cardiac tamponade and
constrictive pericarditis are major lethal complications
of TB pericarditis.4 Apart from antituberculous chemo-
therapy with/without corticosteroid therapy, pericar-
diectomy may be the optimal therapy for TB pericarditis.
As the incidence of TB in Taiwan remains high and the
symptoms of TB pericarditis are nonspecific, a high sus-
picion of TB pericarditis should always be kept in mind
when encountering a patient with pericardial effusion.
CASE REPORT
A 77-year-old man, a retired bank manager, suffered
from chest oppression about 3 weeks prior to this admis-
sion. Percutaneous transluminal coronary angioplasty
Acta Cardiol Sin 2007;23:56�61 56
Case Reports Acta Cardiol Sin 2007;23:56�61
Received: September 12, 2006 Accepted: December 14, 2006Division of Cardiovascular Surgery, Department of Surgery, Kao-hsiung Armed Forces General Hospital, Kaohsiung, Taiwan.Address correspondence and reprint requests to: Dr. Chia-ShenChao, No. 2, Chung-Cheng 1st Road, Kaohsiung 802, Taiwan.Tel: 886-7-749-4963; Fax: 886-7-749-3207; E-mail: [email protected]
with stent for left anterior descending artery lesion was
done under the diagnosis of coronary artery disease with
congestive heart failure at another hospital three weeks
previous. But exertional dyspnea persisted. Under the
suspicion of in-stent restenosis, the patient was admitted
to our hospital for possible coronary arterial bypass
grafting surgery on June 13, 2005.
The patient had had history of hypertension and dia-
betic mellitus for more than 10 years, and he had been
taking medication regularly. He had no habit of smoking
or drinking. Poor appetite, malaise and loss of body
weight were noted in recent weeks. No fever was found.
There was no jugular vein engorgement. Bilateral basal
rales of lungs and pitting edema of both legs were noted.
On the day of admission, echocardiography revealed im-
paired left ventricle (LV) systolic function. Bilateral
blunt costophrenic angles (left side more prominent than
the right) were noted on chest radiography (Figure 1).
Hepatic vein and inferior vena cava engorgement was
noted in abdominal sonography. Pulmonary hypertension
(pulmonary arterial pressure: 41/23 mmHg), high central
venous pressure (21 mmHg) and low cardiac index (1.81
L/min/m2) were found after Swan-Ganz catheterization
measurement. No in-stent restenosis and patency of left
circumflex coronary artery & right coronary artery were
found in cardiac catheterization. Proximal LAD 50%
narrowing was the same as previous. The symptoms im-
proved after the use of inotropic agents. Intermittent low
grade fever (37~38 �C) was found during hospitaliza-
tion, but there were negative results in all the cultures of
sputum, pleural effusion and blood.
On July 6, a follow-up echocardiography revealed
severe hypokinesia of the right ventricle (RV) free wall
with preserved LV systolic function. Tumor of the pe-
ricardium with large pericardial effusion was noted, too.
Thickening of the pericardium was confirmed in a chest
computed tomography (Figure 2). Pericardial window
thru minimal thoracotomy was arranged. Unfortunately,
cardiac tamponade occurred (blood pressure: 80/50
mmHg, heart rate: 138/min and respiratory rate: 30/min,
SpO2: 87%), emergent pericardiotomy via subxyphoid
approach was done. Caseous-like turbid fluid, about 150
cc, was drained (Figure 3). Bilateral thoracic intubations
57 Acta Cardiol Sin 2007;23:56�61
Acute Primary Tuberculous Pericarditis
Figure 2. Chest computed tomography revealed thickened
pericardium, large amount of pericardial effusion with right ventricle
compression and bilateral pleural effusions (left side more prominent
than the right).
Figure 3. Pleural effusion (A) revealed light yellowish color, while
pericardial effusion (B) was caseous-like turbid fluid.
Figure 1. Chest radiography, performed on the day of admission,
showed bilateral blunt costophrenic angles (left side more severe than
the right).
were performed, and a large amount of clear transudate
was drained. The vital signs became stable after the pro-
cedures. The patient was sent to intensive care unit for
recovery. The systolic function of RV and LV were
found normal by echocardiography 2 weeks later.
Numerous acid-fast bacilli were identified in the
specimen from the pericardium (Figure 4). The TB-
polymerase chain reaction (PCR) test of pericardial effu-
sion was positive. Negative finding of acid-fast stain in
sputum and pleural effusion was found. The TB-PCR
test was negative, too. Cultures of sputum and pleural ef-
fusion also yielded negative findings. Four combined
antituberculous chemotherapy (EMB 800 mg + isoniazid
320 mg + pyrazinamide 1000 mg + rifampin 480 mg per
day) plus adjuvant corticosteroid therapy (prednisolone
60 mg per day) were given. The fever subsided on the
next day of regimen. The patient was discharged in good
condition. Dyspnea on exertion (New York Heart As-
sociation Function Class II~III) developed again one
month later. He was re-admitted to our ward under the
impression of constrictive pericarditis on September 5,
2005. Pericardiectomy was done (Figure 5). Numerous
acid-fast bacilli were found in the excised pericardium.
The symptom of exertional dyspnea was absent after
pericardiectomy. After a full course of anti-TB therapy
for 9 months, the patient kept well after one year fol-
low-up.
DISCUSSION
The incidence and mortality of TB pericarditis in de-
veloping countries are still high. The mortality rate in
untreated acute effusive TB pericarditis can approach up
to 85%,1 and was reduced to 3~11% in patients5 who re-
ceived oral medication. In Taiwan, the incidence of
tuberculosis has remained high in recent years. The cli-
nical manifestations in patients with TB pericarditis
usually are nonspecific. Dyspnea, jugular vein disten-
sion, fever (usually < 39 �C), cough, tachycardia, leg
edema and chest tightness or pain were the most com-
monly found clinical manifestations.5 Combined intra-
and extrapulmonary TB had a significantly higher in-
cidence of high fever and a longer duration of fever.
Low-voltage QRS and inverted T-waves were the cha-
racteristic findings of electrocardiogram in TB peri-
carditis in one previous report,4 but this was not seen in
our patient. Although isolated extra-pulmonary involve-
ment only accounted for 22% of cases with TB, pleural
effusion was found in 63% of cases with TB pericardtis.5
Clinicians should have a high index of suspicion of TB
pericarditis when encountering a patient with pericardial
effusion in Taiwan, especially if co-existent pleural effu-
sion is noticed.
The diagnosis is made by the identification of Myco-
bacterium tuberculosis in the pericardial fluid or tissue,
and/or the presence of caseous granulomas in the pe-
ricardium.6 PCR can identify DNA of Mycobacterium
tuberculosis rapidly from only 1 �L of pericardial fluid.7
High adenosine deaminase activity and interferon gam-
ma concentration in pericardial effusion are also di-
agnostic. Pericardial biopsy enables rapid diagnosis with
better sensitivity than pericardiocentesis (100 vs. 33%).
Various antituberculous drug combinations and treat-
ment duration of different lengths (6, 9, 12 months) have
been applied.4,8-10 Although corticosteroids are capable
Acta Cardiol Sin 2007;23:56�61 58
Hsien-Kuo Chin et al.
Figure 4. Numerous acid-fast bacilli were identified from pericardial
material tissue under microscope.
Figure 5. Thickened pericardium with fibrotic change and some
calcification.
of suppressing inflammatory reaction in TB pericar-
ditis,4,10 the use of corticosteroids will inevitably further
compromise the immunity in vulnerable elderly suffer-
ing from TB pericarditis.4 Despite the use of steroids
remaining controversial, a meta analysis of patients with
effusive and constrictive TB pericarditis11,12 suggested
that tuberculosis treatment combined with steroids might
be associated with fewer deaths,13 and less frequent need
for pericardiocentesis or pericardiectomy.10,14 In our pa-
tient, the fever subsided rapidly after the use of pred-
nisolone. High-dose prednisolone (1-2 mg/kg per day)
should be given, since rifampicin induces its liver me-
tabolism. The dose is maintained for 5-7 days and is
progressively tapered to discontinue in 6-8 weeks.1
Since cardiac tamponade and constrictive pericar-
ditis are two major lethal complications of TB peri-
carditis, can we predict or prevent these conditions?
Based on the echocardiographic findings, TB peri-
carditis has been categorized into: (1) early stage, when
only pericardial effusion is found, and (2) advanced
stage, when fibrin strand formation or fibrosis with
thickening of pericardium reflecting constrictive peri-
carditis is detected. An early report indicated that car-
diac tamponade developed in approximately 50% of
patients who did not received adequate treatment in the
first 3 months after the diagnosis of TB pericarditis.5
Yang et al. reported their 14 years’ experience, in-
dicating that 37.5% of patients with early-stage TB pe-
ricarditis developed constrictive pericarditis, while
among patients with advanced-stage disease, 85.7%
subsequently developed pericardial constriction.5 From
the study of Suwan and Potjalongsilp, cardiac tam-
ponade in the early stage of TB pericarditis was the
most predictive factor for subsequent constrictive pe-
ricarditis,12 and the degree of fibrosis of pericardium
before treatment was the most important determinant of
developing constriction.15
In early-stage patients with minimal pericardial effu-
sion, pericardiocentesis with biopsy can be done to
confirm the diagnosis. If cardiac tamponade develops,
creation of a pericardial window should be done. If con-
strictive pericarditis presents, pericardiectomy is the
treatment of choice. The operative mortality for peri-
cardiectomy is around 2.3%. As a poor hemodynamic
result after complete pericardiectomy relates to the pre-
operative degree of constriction and resultant cardio-
myopathy,16 the long-term survival after pericardiectomy
for constrictive pericarditis is related to LV systolic
function, renal function and pulmonary artery pressure;17
early pericardiectomy is recommended when constrictive
pericarditis is diagnosed, or when conditions suggests a
high possibility of developing constrictive pericarditis.18
In conclusion, clinicians in Taiwan should maintain
a high index of suspicion for TB pericarditis when a
patient develops an unexpected pericardial effusion. De-
spite the use of steroids remaining controversial, tubercu-
losis treatment combined with steroids is recommended
if no clear contraindication is present. In patients with
advanced-stage TB, if there is cardiac tamponade in the
early clinical stage, or if severe fibrosis of the peri-
cardium and constrictive pericarditis develop, early pe-
ricardiectomy will be the optimal treatment.
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presumably diagnosed by polymerise chain reaction analysis. Am
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treating tuberculous pericarditis. Cochrane Database Syst Rev
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ticosteroids for tuberculous pericarditis: promising, but not pro-
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berculous constrictive pericarditis and tuberculous pericardial
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2004;97(8):525-35.
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1994;28:251-4.
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Acta Cardiol Sin 2007;23:56�61 60
Hsien-Kuo Chin et al.
Case Reports Acta Cardiol Sin 2007;23:56−61
急性原發性結核心包膜炎
金憲國 張一方 趙家聲高雄市 國軍高雄總醫院 外科部 心臟血管外科
急性原發性結核心包膜炎是一十分罕見但卻致命的一種狀況,它通常導致侷限性心包膜炎
進而造成舒張性心衰竭。我們報告一位 77歲男性在住院前三個月因冠心症合併心衰竭接受左前降支支架置放術。後因氣喘而到本院求診,要求進行冠狀動脈繞道手術。心導管攝影
顯示除左前降支之支架外無明顯病兆。住院後反覆有兩側肋膜積水,積水之所有結核檢查
皆呈陰性。3 週後於心臟超音波檢查發現心包膜有增厚情形且合併大量心包膜液,因為造成心包填塞而從劍突施予緊急心包膜切開術。經組織病理診斷為急性原發性結核心包膜炎,
我們給予抗結核菌藥物合併類固醇輔助治療後病情明顯好轉並於幾天後出院。病患於一個
月後因侷限性心包膜炎而施予心包膜截除術。病患在九個月的抗結核藥物治療後,追蹤至
今滿一年仍保持良好狀態。
關鍵詞:心包填塞、類固醇、心包膜截除術、原發性結核心包膜炎。
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