A Case of Tuberculous Pericarditis: A Rare but Deadly Disease

A 64 year-old homeless alcoholic man presented to the hospital with abdominal pain, 15-lb weight loss, fatigue, and shortness of breath. He denied any past medical or social history, and further review of systems was negative.Objectively, he was a cachectic, chronically ill-appearing gentleman. He was afebrile and normotensive but tachycardic with a pulsus paradoxus. His chest had decreased breath sounds bilaterally. Cardiovascularly, he had distant heart sounds, otherwise normal. His abdominal examination was benign.Laboratory tests were notable for a white blood count of 3.0, a negative human immunodeficiency virus (HIV) test, 2 sets of negative blood cultures, and a negative lumbar puncture. An electrocardiogram (ECG) showed sinus tachycardia with low voltage and diffuse inverted T waves. A chest radiograph was remarkable for cardiomegaly and bilateral pleural effusions.A computed tomography (CT) scan of the chest revealed a large pericardial effusion (5.0 cm in diameter), bilateral pleural effusions, and extensive mediastinal lymphadenopathy. Subsequently, a transthoracic echocardiogram (TTE) evaluating for cardiac tamponade confirmed a large pericardial effusion with respiratory flow variation and prominent fibrinous tissue adherent to the visceral pericardium (Figure 1, Figure 2).Figure 2Short-axis view on transthoracic echocardiogram.View Large Image Figure ViewerDownload (PPT)Surgical drainage of the pericardial effusion and a pericardial window were performed. The pericardium was found to be thick and inflamed; 1500 mL of bloody fluid was drained from the pericardial space. Fluid cytology was negative. Pathology results revealed necrotizing granulomatous inflammation of the pericardial tissue with histochemical stains detecting rare acid-fast bacilli. The patient was empirically started on isoniazid, rifampin, pyrazinamide, pyridoxine, and ethambutol, as well as a course of slow-taper prednisone, and continued on this regimen for 12 months following confirmation of pericardial tuberculosis.DiscussionTuberculosis is a global health problem. It currently infects approximately one-third of the world’s population and kills approximately 2 million individuals annually.1World Health OrganizationGlobal Tuberculosis Control. World Health Organization, Geneva, Switzerland2005Google Scholar Pericarditis caused by tuberculosis is rare, occurring in approximately 2% of US pericardectomy patients but is a dangerous disease with mortality rates reported between 20% and 40%. Causes of pericarditis can be divided into infectious and noninfectious etiologies. Among the most common noninfectious causes include malignancies, such as lung cancer or lymphomas, radiation therapy, sarcoidosis, or collagen vascular diseases. Infectious etiologies include bacteria such as Staphylococcus, Streptococcus, or E. coli; viruses such as echovirus, adenovirus, coxsackieviruses, HIV; or other agents such as Treponema pallidum.2Nardell E.A. Fan D. Shepard J.A. Mark E.J. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-2004. A 30-year-old woman with a pericardial effusion.N Engl J Med. 2004; 351: 279-287Crossref PubMed Scopus (6) Google Scholar Tuberculosis is one of the least common causes of infective pericarditis.Diagnosis of tuberculous pericarditis has improved in recent years, although no diagnostic study is accurate, safe, and easy to perform. TTE has been proposed as a way to differentiate tuberculosis from chronic idiopathic pericardial effusions, taking into consideration the degree of pericardial thickening and presence of exudates and strands in the pericardial space.3George S. Salama A.L. Uthaman B. Cherian G. Echocardiography in differentiating tuberculous from chronic idiopathic pericardial effusion.Heart. 2004; 90: 1338-1339Crossref PubMed Scopus (22) Google ScholarManagement and treatment of tuberculous pericarditis with a hemodynamically significant pericardial effusion involves surgical pericardial window placement or pericardiocentesis, as well as antitubercular medications. The use of corticosteroids as an adjuvant treatment has been explored with promising results. Two randomized trials in Transkei, South Africa, where tuberculous pericarditis is common, involved the use of prednisolone versus placebo in addition to standard tuberculosis regimen and possible pericardial drainage in patients with either effusion or constrictive pericarditis. After a 10-year follow-up, the use of prednisolone resulted in a higher rate of clinical improvement from pericarditis, as well as reducing the need for further pericardial drainage and improving survival.4Strang J.I. Nunn A.J. Johnson D.A. Casbard A. Gibson D.G. Girling D.J. Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei results at 10 years follow-up.QJM. 2004; 97: 525-535Crossref PubMed Scopus (75) Google Scholar A 64 year-old homeless alcoholic man presented to the hospital with abdominal pain, 15-lb weight loss, fatigue, and shortness of breath. He denied any past medical or social history, and further review of systems was negative. Objectively, he was a cachectic, chronically ill-appearing gentleman. He was afebrile and normotensive but tachycardic with a pulsus paradoxus. His chest had decreased breath sounds bilaterally. Cardiovascularly, he had distant heart sounds, otherwise normal. His abdominal examination was benign. Laboratory tests were notable for a white blood count of 3.0, a negative human immunodeficiency virus (HIV) test, 2 sets of negative blood cultures, and a negative lumbar puncture. An electrocardiogram (ECG) showed sinus tachycardia with low voltage and diffuse inverted T waves. A chest radiograph was remarkable for cardiomegaly and bilateral pleural effusions. A computed tomography (CT) scan of the chest revealed a large pericardial effusion (5.0 cm in diameter), bilateral pleural effusions, and extensive mediastinal lymphadenopathy. Subsequently, a transthoracic echocardiogram (TTE) evaluating for cardiac tamponade confirmed a large pericardial effusion with respiratory flow variation and prominent fibrinous tissue adherent to the visceral pericardium (Figure 1, Figure 2). Surgical drainage of the pericardial effusion and a pericardial window were performed. The pericardium was found to be thick and inflamed; 1500 mL of bloody fluid was drained from the pericardial space. Fluid cytology was negative. Pathology results revealed necrotizing granulomatous inflammation of the pericardial tissue with histochemical stains detecting rare acid-fast bacilli. The patient was empirically started on isoniazid, rifampin, pyrazinamide, pyridoxine, and ethambutol, as well as a course of slow-taper prednisone, and continued on this regimen for 12 months following confirmation of pericardial tuberculosis. DiscussionTuberculosis is a global health problem. It currently infects approximately one-third of the world’s population and kills approximately 2 million individuals annually.1World Health OrganizationGlobal Tuberculosis Control. World Health Organization, Geneva, Switzerland2005Google Scholar Pericarditis caused by tuberculosis is rare, occurring in approximately 2% of US pericardectomy patients but is a dangerous disease with mortality rates reported between 20% and 40%. Causes of pericarditis can be divided into infectious and noninfectious etiologies. Among the most common noninfectious causes include malignancies, such as lung cancer or lymphomas, radiation therapy, sarcoidosis, or collagen vascular diseases. Infectious etiologies include bacteria such as Staphylococcus, Streptococcus, or E. coli; viruses such as echovirus, adenovirus, coxsackieviruses, HIV; or other agents such as Treponema pallidum.2Nardell E.A. Fan D. Shepard J.A. Mark E.J. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-2004. A 30-year-old woman with a pericardial effusion.N Engl J Med. 2004; 351: 279-287Crossref PubMed Scopus (6) Google Scholar Tuberculosis is one of the least common causes of infective pericarditis.Diagnosis of tuberculous pericarditis has improved in recent years, although no diagnostic study is accurate, safe, and easy to perform. TTE has been proposed as a way to differentiate tuberculosis from chronic idiopathic pericardial effusions, taking into consideration the degree of pericardial thickening and presence of exudates and strands in the pericardial space.3George S. Salama A.L. Uthaman B. Cherian G. Echocardiography in differentiating tuberculous from chronic idiopathic pericardial effusion.Heart. 2004; 90: 1338-1339Crossref PubMed Scopus (22) Google ScholarManagement and treatment of tuberculous pericarditis with a hemodynamically significant pericardial effusion involves surgical pericardial window placement or pericardiocentesis, as well as antitubercular medications. The use of corticosteroids as an adjuvant treatment has been explored with promising results. Two randomized trials in Transkei, South Africa, where tuberculous pericarditis is common, involved the use of prednisolone versus placebo in addition to standard tuberculosis regimen and possible pericardial drainage in patients with either effusion or constrictive pericarditis. After a 10-year follow-up, the use of prednisolone resulted in a higher rate of clinical improvement from pericarditis, as well as reducing the need for further pericardial drainage and improving survival.4Strang J.I. Nunn A.J. Johnson D.A. Casbard A. Gibson D.G. Girling D.J. Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei results at 10 years follow-up.QJM. 2004; 97: 525-535Crossref PubMed Scopus (75) Google Scholar Tuberculosis is a global health problem. It currently infects approximately one-third of the world’s population and kills approximately 2 million individuals annually.1World Health OrganizationGlobal Tuberculosis Control. World Health Organization, Geneva, Switzerland2005Google Scholar Pericarditis caused by tuberculosis is rare, occurring in approximately 2% of US pericardectomy patients but is a dangerous disease with mortality rates reported between 20% and 40%. Causes of pericarditis can be divided into infectious and noninfectious etiologies. Among the most common noninfectious causes include malignancies, such as lung cancer or lymphomas, radiation therapy, sarcoidosis, or collagen vascular diseases. Infectious etiologies include bacteria such as Staphylococcus, Streptococcus, or E. coli; viruses such as echovirus, adenovirus, coxsackieviruses, HIV; or other agents such as Treponema pallidum.2Nardell E.A. Fan D. Shepard J.A. Mark E.J. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-2004. A 30-year-old woman with a pericardial effusion.N Engl J Med. 2004; 351: 279-287Crossref PubMed Scopus (6) Google Scholar Tuberculosis is one of the least common causes of infective pericarditis. Diagnosis of tuberculous pericarditis has improved in recent years, although no diagnostic study is accurate, safe, and easy to perform. TTE has been proposed as a way to differentiate tuberculosis from chronic idiopathic pericardial effusions, taking into consideration the degree of pericardial thickening and presence of exudates and strands in the pericardial space.3George S. Salama A.L. Uthaman B. Cherian G. Echocardiography in differentiating tuberculous from chronic idiopathic pericardial effusion.Heart. 2004; 90: 1338-1339Crossref PubMed Scopus (22) Google Scholar Management and treatment of tuberculous pericarditis with a hemodynamically significant pericardial effusion involves surgical pericardial window placement or pericardiocentesis, as well as antitubercular medications. The use of corticosteroids as an adjuvant treatment has been explored with promising results. Two randomized trials in Transkei, South Africa, where tuberculous pericarditis is common, involved the use of prednisolone versus placebo in addition to standard tuberculosis regimen and possible pericardial drainage in patients with either effusion or constrictive pericarditis. After a 10-year follow-up, the use of prednisolone resulted in a higher rate of clinical improvement from pericarditis, as well as reducing the need for further pericardial drainage and improving survival.4Strang J.I. Nunn A.J. Johnson D.A. Casbard A. Gibson D.G. Girling D.J. Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei results at 10 years follow-up.QJM. 2004; 97: 525-535Crossref PubMed Scopus (75) Google Scholar