Tuberculous pericarditis medical therapy
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Tuberculous pericarditis Microchapters |
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Differentiating Tuberculous pericarditis from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Ahmed Zaghw, M.D. [2]
Overview
Medical Therapy
Anti-Tuberculosis Chemotherapy
With the use of antituberculosis chemotherapy, survival rate in tuberculous pericarditis has improved dramatically. Mortality rate in preantibiotic era was 80-90%[1]. At present it is 8-17%[2][3] and 17-34% if associated with HIV[4]. A 2months course of isoniazid, pyrazinamide, rifampicin, and ethambutol followed by 4months course of isoniazid and rifampicin is shown to be effective[5]. Short course chemotherapy is beneficial in HIV infected patients.[6] Antituberculous therapy has an additional clinical benefit in reduction of constrictive pericarditis, from 88 % down to 10-20 % of treated cases.[7] [8]
The treatment regimen varies among 3 patient groups; sero-negative HIV, sero-positive HIV and drug-resistant tuberculosis.
Empirical Anti-Tuberculosis Therapy
It should be considered that in developing countries where TB is endemic and in cases with high clinical suspicion of tuberculous pericarditis, starting with empiric antituberculous therapy is appropriate before establishing a definitive diagnosis. In the clinical settings where the diagnosis cannot be established based on bacteriology, histology, or pericardial fluid analysis, clinical response to antituberculous therapy serves as support for a diagnosis of tuberculous pericarditis.[9] In developed countries where TB is not endemic, antituberculous therapy should generally not be initiated empirically in the absence of definitive diagnosis.[10]
Standard regimens for new TB patients (with presumed, or known, to have drug-susceptible TB)
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† WHO no longer recommends omission of ethambutol during the intensive phase of treatment for patients with non-cavitary, smear-negative PTB or EPEPTB who are known to be HIV-negative.
Standard regimens for new TB patients (with known or suspected high levels of Isoniazid resistance TB)∞
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- ∞ Applies also in the countries with high levels of isoniazid resistance in new TB patients, and where isoniazid drug susceptibility testing in new patients is not done (or results are unavailable) before the continuation phase begins
2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR in these patients or if such data are not available
Dosing Frequency for New TB Adult Patients with Active Tuberculosis caused by Drug-Susceptible Organisms[11]
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- DOT; Direct Observed Therapy
- † if patient is getting DOT and not living with HIV infected patient or HIV prevalent setting
Level Of Evidence in Dosing Frequency
The level of evidence of the dosage frequency came from the systematic review showed that equivalent efficacy of daily intensive-phase dosing followed by two times weekly continuation phase, however twice weekly dosing is not recommended on operational grounds. Also showed that the daily (rather than three times weekly) intensive-phase dosing may also help to prevent acquired drug resistance in TB patients starting treatment with isoniazid resistance. The systematic review found that patients with isoniazid resistance treated with a three times weekly intensive phase had significantly higher risks of failure and acquired drug resistance than those treated with daily dosing during the intensive phase.[12]
Role of Corticosteroids in Tuberculous pericarditis
The corticosteroids can shorten the time to resolution of clinical symptoms, decrease reaccumulation of fluid and reduce the mortality.[13] But none of the study results were statistically significant. However, other studies claimed that corticosteroids do not appear to affect the likelihood of pericardial effusion reaccumulation or progression to constrictive pericarditis.[14]
The American Thoracic Society, CDC, and Infectious Diseases Society of America recommends in 2003 the use of corticosteroids (prednisone) as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of antituberculosis therapy[15]. However the Infectious Diseases Society of America recommends a shorter course of 60 mg of prednisone daily, get tapered by 10/mg day each week over a six-week period in HIV. In contrary to the standard full 11 week course, the 6 week course has demonstrated efficacy in HIV-seropositive patients with tuberculous pericarditis.[16]
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† or the equivalent dose of prednisolone
References
- ↑ Harvey AM, Whitehill MR. Tuberculous pericarditis. Medicine. 1937; 16: 45–94
- ↑ Desai HN (1979). "Tuberculous pericarditis. A review of 100 cases". S Afr Med J. 55 (22): 877–80. PMID 472922.
- ↑ Bhan GL (1980). "Tuberculous pericarditis". J Infect. 2 (4): 360–4. PMID 7185934.
- ↑ Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A (2000). "Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients". Heart. 84 (2): 183–8. PMC 1760932. PMID 10908256.
- ↑ Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbaro JA (1990). "A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen". Ann Intern Med. 112 (6): 407–15. PMID 2106816.
- ↑ Perriëns JH, St Louis ME, Mukadi YB, Brown C, Prignot J, Pouthier F; et al. (1995). "Pulmonary tuberculosis in HIV-infected patients in Zaire. A controlled trial of treatment for either 6 or 12 months". N Engl J Med. 332 (12): 779–84. doi:10.1056/NEJM199503233321204. PMID 7862181.
- ↑ Gooi, HC.; Smith, JM. (1978). "Tuberculous pericarditis in Birmingham". Thorax. 33 (1): 94–6. PMID 644546. Unknown parameter
|month=ignored (help) - ↑ Long, R.; Younes, M.; Patton, N.; Hershfield, E. (1989). "Tuberculous pericarditis: long-term outcome in patients who received medical therapy alone". Am Heart J. 117 (5): 1133–9. PMID 2711975. Unknown parameter
|month=ignored (help) - ↑ Mayosi, BM.; Burgess, LJ.; Doubell, AF. (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703. Unknown parameter
|month=ignored (help) - ↑ Soler-Soler, J.; Sagristà-Sauleda, J.; Permanyer-Miralda, G. (2001). "Management of pericardial effusion". Heart. 86 (2): 235–40. PMID 11454853. Unknown parameter
|month=ignored (help) - ↑ "http://whqlibdoc.who.int/publications/2008/9789241547581_eng.pdf" (PDF). External link in
|title=(help) - ↑ "http://whqlibdoc.who.int/publications/2008/9789241547581_eng.pdf" (PDF). External link in
|title=(help) - ↑ Dooley, DP.; Carpenter, JL.; Rademacher, S. (1997). "Adjunctive corticosteroid therapy for tuberculosis: a critical reappraisal of the literature". Clin Infect Dis. 25 (4): 872–87. PMID 9356803. Unknown parameter
|month=ignored (help) - ↑ Ntsekhe, M.; Wiysonge, C.; Volmink, JA.; Commerford, PJ.; Mayosi, BM. (2003). "Adjuvant corticosteroids for tuberculous pericarditis: promising, but not proven". QJM. 96 (8): 593–9. PMID 12897345. Unknown parameter
|month=ignored (help) - ↑ American Thoracic Society. CDC. Infectious Diseases Society of America (2003). "Treatment of tuberculosis". MMWR Recomm Rep. 52 (RR-11): 1–77. PMID 12836625.
- ↑ "http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf" (PDF). Retrieved 20 January 2014. External link in
|title=(help)