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| {{Pericarditis}} | | {{Tuberculous pericarditis}} |
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| {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.
| | '''For patient information click, [[Pericarditis (patient information)|here]].''' |
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| ==Overview==
| | '''To go back to the main page on Pericarditis, click [[Pericarditis|here]].''' |
| The incidence of [[tuberculosis]] caused by ''[[Mycobacterium tuberculosis]]'' and its complications has significantly decreased in developed nations while it remains high in developing countries. Approximately one third of the world population is believed to be infected with [[tuberculosis]](TB)<ref name="pmid18810682">{{cite journal| author=Lönnroth K, Raviglione M| title=Global epidemiology of tuberculosis: prospects for control. | journal=Semin Respir Crit Care Med | year= 2008 | volume= 29 | issue= 5 | pages= 481-91 | pmid=18810682 | doi=10.1055/s-0028-1085700 | pmc= | url= }} </ref>. In 2006, the [[WHO]] estimated the global prevalence of active [[TB]]<ref>WHO. Global Tuberculosis control. WHO/HTM/TB/2008.393. Geneva: World Health Organization; 2008. Available online at http://www.who.int/tb/publications/global_report/2008/en/index.html (Accessed June 27, 2011)</ref> to be 14.4 million cases. [[TB]] accounts for 1.7 million deaths worldwide. One of the important complications of [[TB]] is [[pericarditis]] which is inflammation of the pericardial sac that encases the heart.
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| ==Epidemiology and demographics==
| | {{CMG}}; '''Associate Editors-In-Chief:''' {{Fs}}, [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. |
| Tuberculous pericarditis is found in approximately 1-2% of patients with [[pulmonary tuberculosis]]<ref name="pmid2046135">{{cite journal| author=Fowler NO| title=Tuberculous pericarditis. | journal=JAMA | year= 1991 | volume= 266 | issue= 1 | pages= 99-103 | pmid=2046135 | doi= | pmc= | url= }} </ref><ref name="pmid7377888">{{cite journal| author=Larrieu AJ, Tyers GF, Williams EH, Derrick JR| title=Recent experience with tuberculous pericarditis. | journal=Ann Thorac Surg | year= 1980 | volume= 29 | issue= 5 | pages= 464-8 | pmid=7377888 | doi= | pmc= | url= }} </ref>. It is the most common cause of pericarditis in Africa and other developing countries where TB is a major public health problem<ref>Mayosi BM, Volmink JA, Commerford PJ. Pericardial disease: an evidence-based approach to diagnosis and treatment. In: Yusuf S, Cairns JA, Camm AJ, Fallen BJ, eds. Evidence-Based Cardiology. 2nd ed. London: BMJ Books; 2003: 735–748.</ref>. The incidence is increasing rapidly in the presence of [[HIV]]<ref name="pmid1967676">{{cite journal| author=Cegielski JP, Ramiya K, Lallinger GJ, Mtulia IA, Mbaga IM| title=Pericardial disease and human immunodeficiency virus in Dar es Salaam, Tanzania. | journal=Lancet | year= 1990 | volume= 335 | issue= 8683 | pages= 209-12 | pmid=1967676 | doi= | pmc= | url= }} </ref>.
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| In a study at Western Cape Province of South Africa, tuberculous pericarditis was noted in 69.5% of patients who were referred for diagnostic [[pericardiocentesis]]. It should noted that one half of the patients were infected with [[HIV]]<ref name="pmid15962545">{{cite journal| author=Reuter H, Burgess LJ, Doubell AF| title=Epidemiology of pericardial effusions at a large academic hospital in South Africa. | journal=Epidemiol Infect | year= 2005 | volume= 133 | issue= 3 | pages= 393-9 | pmid=15962545 | doi= | pmc=PMC2870262 | url= }} </ref>. In contrast, the incidence of tuberculous pericarditis is 4% in developed countries<ref name="pmid3351140">{{cite journal| author=Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J| title=Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. | journal=J Am Coll Cardiol | year= 1988 | volume= 11 | issue= 4 | pages= 724-8 | pmid=3351140 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3351140 }} </ref>.
| | '''''Synonyms and keywords:''''' TB pericarditis |
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| ==Natural history and complications== | | == [[Tuberculous pericarditis overview|Overview]] == |
| Tuberculous pericarditis often has a complicated course and poor clinical outcomes. It can lead to '''[[pericardial effusion]]''' and subsequently, '''[[cardiac tamponade]]''' which may require urgent intervention including [[pericardiocentesis]]. The mortality rate of tuberculous pericarditis in the preantibiotic era was 80-90%<ref>Harvey AM, Whitehill MR. Tuberculous pericarditis. Medicine. 1937; 16: 45–94</ref>. The mortality rate in the modern era is currently 8-17%<ref name="pmid472922">{{cite journal| author=Desai HN| title=Tuberculous pericarditis. A review of 100 cases. | journal=S Afr Med J | year= 1979 | volume= 55 | issue= 22 | pages= 877-80 | pmid=472922 | doi= | pmc= | url= }} </ref><ref name="pmid7185934">{{cite journal| author=Bhan GL| title=Tuberculous pericarditis. | journal=J Infect | year= 1980 | volume= 2 | issue= 4 | pages= 360-4 | pmid=7185934 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7185934 }} </ref> and is 17-34% if the TB is associated with HIV<ref name="pmid10908256">{{cite journal| author=Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A| title=Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. | journal=Heart | year= 2000 | volume= 84 | issue= 2 | pages= 183-8 | pmid=10908256 | doi= | pmc=PMC1760932 | url= }} </ref>.
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| Tuberculous pericarditis can also cause '''[[heart failure]]''' as observed in Eastern Cape and Zimbabwe where it is a common cause, but less common than [[rheumatic heart disease]]. In this region, TB pericarditis is a more common cause of heart failure than [[hypertensive heart disease]] and [[cardiomyopathy]]<ref name="pmid6509811">{{cite journal| author=Strang JI| title=Tuberculous pericarditis in Transkei. | journal=Clin Cardiol | year= 1984 | volume= 7 | issue= 12 | pages= 667-70 | pmid=6509811 | doi= | pmc= | url= }} </ref><ref name="pmid9810393">{{cite journal| author=Hakim JG, Manyemba J| title=Cardiac disease distribution among patients referred for echocardiography in Harare, Zimbabwe. | journal=Cent Afr J Med | year= 1998 | volume= 44 | issue= 6 | pages= 140-4 | pmid=9810393 | doi= | pmc= | url= }} </ref>
| | == [[Tuberculous pericarditis historical perspective|Historical Perspective]] == |
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| '''[[Constrictive pericarditis]]''' is another complication of tuberculous pericarditis occurring in 30-60% of patients despite prompt antituberculosis treatment and the use of corticosteroids<ref name="pmid14443596">{{cite journal| author=SCHRIRE V| title=Experience with pericarditis at Groote Schuur Hospital, Cape Town: an analysis of one hundred and sixty cases studied over a six-year period. | journal=S Afr Med J | year= 1959 | volume= 33 | issue= | pages= 810-7 | pmid=14443596 | doi= | pmc= | url= }} </ref><ref name="pmid3351140">{{cite journal| author=Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J| title=Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. | journal=J Am Coll Cardiol | year= 1988 | volume= 11 | issue= 4 | pages= 724-8 | pmid=3351140 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3351140 }} </ref>
| | == [[Tuberculous pericarditis classification|Classification]] == |
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| ==Pathophysiology== | | == [[Tuberculous pericarditis pathophysiology|Pathophysiology]] == |
| Tuberculous pericarditis develops as a result of lymphatic spread from peritracheal, peribronchial or [[mediastinal lymphnodes]] or by contiguous spread from a focus of infection in the lung or pleura. This causes acute inflammation of the pericardium with infiltration of polymorphonuclear ([[PMN]]) leukocytes and pericardial vascularization. This may lead to [[pericardial effusion]] and fibrinous changes of the pericardium. There are four pathologic stages of involvement:<ref name="pmid18610109">{{cite journal| author=Peel AA| title=TUBERCULOUS PERICARDITIS. | journal=Br Heart J | year= 1948 | volume= 10 | issue= 3 | pages= 195-207 | pmid=18610109 | doi= | pmc=PMC481044 | url= }} </ref><ref name="pmid4050698">{{cite journal| author=Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J| title=Primary acute pericardial disease: a prospective series of 231 consecutive patients. | journal=Am J Cardiol | year= 1985 | volume= 56 | issue= 10 | pages= 623-30 | pmid=4050698 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050698 }} </ref><ref name="pmid16330703">{{cite journal| author=Mayosi BM, Burgess LJ, Doubell AF| title=Tuberculous pericarditis. | journal=Circulation | year= 2005 | volume= 112 | issue= 23 | pages= 3608-16 | pmid=16330703 | doi=10.1161/CIRCULATIONAHA.105.543066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16330703 }} </ref>
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| :'''Stage 1:''' Presence of diffuse [[fibrin]] deposition, [[granulomas]] and abundant [[mycobacterium]]
| | == [[Tuberculous pericarditis causes|Causes]] == |
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| :'''Stage 2:''' Development of [[serous]] or serosanguineous pericardial effusion with a predominantly lymphocytic exudate with [[monocytes]] and [[foam cell]]s
| | == [[Pericarditis differential diagnosis|Differentiating Tuberculous Pericarditis from other Diseases]] == |
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| :'''Stage 3:''' Absorption of effusion with organization of granulomatous caseation and thickening of pericardium secondary to deposition of [[fibrin]] and [[collagen]].
| | == [[Tuberculous pericarditis epidemiology and demographics|Epidemiology and Demographics]] == |
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| :'''Stage 4:''' Development of [[constrictive pericarditis]]. Pericardial space is obliterated by dense adhesions with marked thickening of [[parietal]] layer and replacement of [[granulomas]] by fibrous tissue.
| | == [[Tuberculous pericarditis risk factors|Risk Factors]] == |
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| [[Effusive constrictive pericarditis]]<ref name="pmid14749455">{{cite journal| author=Sagristà-Sauleda J, Angel J, Sánchez A, Permanyer-Miralda G, Soler-Soler J| title=Effusive-constrictive pericarditis. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 5 | pages= 469-75 | pmid=14749455 | doi=10.1056/NEJMoa035630 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14749455 }} </ref> may be seen in some patients. The visceral pericardium thickens with fibrin deposition (changes of [[constrictive pericarditis]]) and concomitantly there is presence of pericardial effusion which may present as [[cardiac tamponade]]. In this scenario, the [[diastolic pressure]] continues to be elevated after [[pericardiocentesis]] due to persistent constriction. | | == [[Tuberculous pericarditis screening|Screening]] == |
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| | == [[Tuberculous pericarditis natural history|Natural History, Complications and Prognosis]] == |
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| ==Diagnosis== | | ==Diagnosis== |
| Tuberculous pericarditis has a variable clinical presentation and should be considered in the evaluation of all cases of pericarditis that are not self-limiting<ref name="pmid3351140">{{cite journal| author=Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J| title=Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. | journal=J Am Coll Cardiol | year= 1988 | volume= 11 | issue= 4 | pages= 724-8 | pmid=3351140 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3351140 }} </ref>. It is one of the difficult disease to diagnose and hence several diagnostic tools are employed<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid12923044">{{cite journal| author=Maisch B, Ristić AD| title=Practical aspects of the management of pericardial disease. | journal=Heart | year= 2003 | volume= 89 | issue= 9 | pages= 1096-103 | pmid=12923044 | doi= | pmc=PMC1767862 | url= }} </ref>. | | [[Tuberculous pericarditis diagnostic study of choice|Diagnostic study of choice]] | [[Tuberculous pericarditis history and symptoms|History and Symptoms]] | [[Tuberculous pericarditis physical examination|Physical Examination]] | [[Tuberculous pericarditis laboratory findings|Laboratory Findings]] | [[Tuberculous pericarditis electrocardiogram|Electrocardiogram]] | [[Tuberculous pericarditis x ray|X-Ray Findings]] | [[Tuberculous pericarditis echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Tuberculous pericarditis CT scan|CT-Scan Findings]] | [[Tuberculous pericarditis MRI|MRI Findings]] | [[Tuberculous pericarditis other imaging findings|Other Imaging Findings]] | [[Tuberculous pericarditis other diagnostic studies|Other Diagnostic Studies]] |
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| ===History and symptoms===
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| The patient may present with the following symptoms:
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| *[[Fever]]
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| *[[Weight loss]]
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| *[[Night sweats]]
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| *[[Cough]]
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| *[[breathlessness]]
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| *[[Chest pain]] which changes with posture
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| *[[Malaise]]
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| *[[Ankle edema]]
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| The frequency and severity of the above symptoms varies with the stage of the infection, the degree of involvement of the [[pericardium]], and the degree of extrapericardial infection.
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| ===Physical examination===
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| Patients present with [[fever]] and [[cachexia]].
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| '''Vitals:''' [[Tachycardia]], [[pulsus paradoxus]] and hypotension(in [[cardiac tamponade]])
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| '''Neck:''' [[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]]
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| '''Chest:''' Pleural dullness, decreased breath sounds, pericardial knock, [[pericardial rub]] and distant [[heart sounds]]
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| '''Abdomen:''' [[Hepatomegaly]], [[ascites]]
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| '''Extremities:''' [[Ankle edema]]
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| ===Chest X-ray===
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| Pulmonary infiltration by the bacterium may be seen in approximately 32% of cases<ref name="pmid4593515">{{cite journal| author=Fowler NO, Manitsas GT| title=Infectious pericarditis. | journal=Prog Cardiovasc Dis | year= 1973 | volume= 16 | issue= 3 | pages= 323-36 | pmid=4593515 | doi= | pmc= | url= }} </ref>, [[pleural effusion]] in 40% to 60%, and [[cardiomegaly]] in about 90% of patients with tuberculous pericarditis<ref name="pmid15915278">{{cite journal| author=Reuter H, Burgess LJ, Doubell AF| title=Role of chest radiography in diagnosing patients with tuberculous pericarditis. | journal=Cardiovasc J S Afr | year= 2005 | volume= 16 | issue= 2 | pages= 108-11 | pmid=15915278 | doi= | pmc= | url= }} </ref><ref name="pmid5410398">{{cite journal| author=Rooney JJ, Crocco JA, Lyons HA| title=Tuberculous pericarditis. | journal=Ann Intern Med | year= 1970 | volume= 72 | issue= 1 | pages= 73-81 | pmid=5410398 | doi= | pmc= | url= }} </ref>.
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| [http://www.radiopaedia.org Image shown below is courtesy of Radiopedia]
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| [[Image:Tuberculous pericarditis.jpg|thumb|350px|left|14 year old child with tubercular pleural and pericardial effusion. Decortication was performed on the left side. The pericardial effusion was aspirated with a wide bore needle on 3 occasions, it reaccumulated immediately.]] | |
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| ===Electrocardiogram===
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| [[ECG]] may show non-specific ST-T–wave changes<ref name="pmid14443596">{{cite journal| author=SCHRIRE V| title=Experience with pericarditis at Groote Schuur Hospital, Cape Town: an analysis of one hundred and sixty cases studied over a six-year period. | journal=S Afr Med J | year= 1959 | volume= 33 | issue= | pages= 810-7 | pmid=14443596 | doi= | pmc= | url= }} </ref><ref name="pmid11447490">{{cite journal| author=Smedema JP, Katjitae I, Reuter H, Burgess L, Louw V, Pretorius M et al.| title=Twelve-lead electrocardiography in tuberculous pericarditis. | journal=Cardiovasc J S Afr | year= 2001 | volume= 12 | issue= 1 | pages= 31-4 | pmid=11447490 | doi= | pmc= | url= }} </ref>. Characteristic EKG finding of acute pericarditis, PR-segment deviation and diffuse ST-segment elevation are found in only 9-11% of cases<ref name="pmid5410398">{{cite journal| author=Rooney JJ, Crocco JA, Lyons HA| title=Tuberculous pericarditis. | journal=Ann Intern Med | year= 1970 | volume= 72 | issue= 1 | pages= 73-81 | pmid=5410398 | doi= | pmc= | url= }} </ref><ref name="pmid11447490">{{cite journal| author=Smedema JP, Katjitae I, Reuter H, Burgess L, Louw V, Pretorius M et al.| title=Twelve-lead electrocardiography in tuberculous pericarditis. | journal=Cardiovasc J S Afr | year= 2001 | volume= 12 | issue= 1 | pages= 31-4 | pmid=11447490 | doi= | pmc= | url= }} </ref>. The presence of micro-voltage and [[electrical alternans]] suggests pericardial effusion and tamponade. | |
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| [[Image:12leadpericarditis.png|thumb|500px|left|ECG in acute pericarditis showing diffuse ST elevation]][[Image:PulsusAlternans.jpg|thumb|500px|center|Electrical alternans]]
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| ===Echocardiography===
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| Echocardiographic findings in '''[[constrictive pericarditis]]''' include thickened [[pericardium]] with dilated [[atria]] and [[venae cavae]]. In '''[[pericardial effusion]]''', large hypoechoic regions are seen surrounding the heart with presence of oscillatory motion of heart. '''[[Cardiac tamponade]]''' demonstrates right atrial collapse, right ventricular diastolic collapse, and increased variation of mitral and tricuspid flow with respiration.
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| '''Below is a video demonstrating echocardiographic features of cardiac tamponade'''
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| <youtube v=YWVI6rRTIzU/>
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| ===MRI===
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| Below is a video demonstrating MR findings of constrictive pericarditis where, in mid-diastole, the thickened pericardium begins to restrict right ventricular filling, causing a rapid increase in ventricular pressure. Early changes of septal flattening and bowing of the interventricular septum toward the left ventricle (normally concave in shape toward the left ventricle during diastolic filling) are seen. This pressure change results in diastolic septal dysfunction, the septal bounce described in echocardiography.
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| <youtube v=5srXVJdWIAM/>
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| ===Cardiac catheterization===
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| *'''Cardiac tamponade:''' There is equalization of pressures in all four chambers of heart. The right atrial pressure equals the right ventricular end diastolic pressure equals the pulmonary artery diastolic pressure.
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| *'''Constrictive pericarditis:''' Equalization of elevated right atrial and pulmonary artery wedge pressures may be noted with a diastolic dip and plateau in the right ventricular tracing.
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| *'''Effusive constrictive pericarditis:''' Cardiac tamponade findings are noted initially. Findings of constrictive pericarditis are unmasked following [[pericardiocentesis]].
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| ===Tuberculin skin test===
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| Patients with tuberculous pericarditis most often have positive PPD test<ref name="pmid5410398">{{cite journal| author=Rooney JJ, Crocco JA, Lyons HA| title=Tuberculous pericarditis. | journal=Ann Intern Med | year= 1970 | volume= 72 | issue= 1 | pages= 73-81 | pmid=5410398 | doi= | pmc= | url= }} </ref>. However [[immunocompromised]] patients such as those with [[HIV]] infection may have false negative tuberculin test<ref name="pmid7718831">{{cite journal| author=Cegielski JP, Lwakatare J, Dukes CS, Lema LE, Lallinger GJ, Kitinya J et al.| title=Tuberculous pericarditis in Tanzanian patients with and without HIV infection. | journal=Tuber Lung Dis | year= 1994 | volume= 75 | issue= 6 | pages= 429-34 | pmid=7718831 | doi= | pmc= | url= }} </ref>. In developing countries where [[TB]] is endemic, tuberculin skin test may be of little value secondary to high prevalence of [[TB]] and [[BCG]] vaccination<ref name="pmid7796085">{{cite journal| author=Ng TT, Strang JI, Wilkins EG| title=Serodiagnosis of pericardial tuberculosis. | journal=QJM | year= 1995 | volume= 88 | issue= 5 | pages= 317-20 | pmid=7796085 | doi= | pmc= | url= }} </ref>.
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| ===Pericardiocentesis===
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| [[Pericardiocentesis]] should be performed in patients with [[cardiac tamponade]], a large symptomatic[[pericardial effusion]], an effusion that does not resolve with traditional treatment ([[NSAIDs]]), and an effusion that is suspected to be due to malignancy, a bacterial infection or [[tuberculosis]]. Among patients with tuberculous pericarditis, the pericardial fluid is blood-stained in approximately 80% of patients<ref>Mayosi BM, Volmink JA, Commerford PJ. Pericardial disease: an evidence-based approach to diagnosis and treatment. In: Yusuf S, Cairns JA, Camm AJ, Fallen BJ, eds. Evidence-Based Cardiology. 2nd ed. London: BMJ Books; 2003: 735–748.</ref>. Tuberculous pericardial fluid is often [[exudative]] with high protein, [[LDH]] and [[leukocyte]] levels<ref name="pmid12019920">{{cite journal| author=Burgess LJ, Reuter H, Carstens ME, Taljaard JJ, Doubell AF| title=Cytokine production in patients with tuberculous pericarditis. | journal=Int J Tuberc Lung Dis | year= 2002 | volume= 6 | issue= 5 | pages= 439-46 | pmid=12019920 | doi= | pmc= | url= }} </ref>. This fluid can be used to test for the presence of [[acid-fast bacilli]] which may be detected in up to approximately 40% of patients with tuberculous pericarditis<ref name="pmid2046135">{{cite journal| author=Fowler NO| title=Tuberculous pericarditis. | journal=JAMA | year= 1991 | volume= 266 | issue= 1 | pages= 99-103 | pmid=2046135 | doi= | pmc= | url= }} </ref>. Culturing the sample may increase the bacterial yield. If [[pericardiocentesis]] is not diagnostic, a pericardial biopsy may be performed. However, less invasive studies such as sputum examination, [[gastric washings]], [[urine culture]], and right [[scalene]] lymph node biopsy may be tried before biopsy. | |
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| *'''[[Polymerase chain reaction]](PCR)''' is another test that helps in detecting presence of [[DNA]] of [[Mycobacterium tuberculosis]]<ref name="pmid2572798">{{cite journal| author=Brisson-Noël A, Gicquel B, Lecossier D, Lévy-Frébault V, Nassif X, Hance AJ| title=Rapid diagnosis of tuberculosis by amplification of mycobacterial DNA in clinical samples. | journal=Lancet | year= 1989 | volume= 2 | issue= 8671 | pages= 1069-71 | pmid=2572798 | doi= | pmc= | url= }} </ref><ref name="pmid10409547">{{cite journal| author=Rana BS, Jones RA, Simpson IA| title=Recurrent pericardial effusion: the value of polymerase chain reaction in the diagnosis of tuberculosis. | journal=Heart | year= 1999 | volume= 82 | issue= 2 | pages= 246-7 | pmid=10409547 | doi= | pmc=PMC1729120 | url= }} </ref><ref name="pmid9399529">{{cite journal| author=Cegielski JP, Devlin BH, Morris AJ, Kitinya JN, Pulipaka UP, Lema LE et al.| title=Comparison of PCR, culture, and histopathology for diagnosis of tuberculous pericarditis. | journal=J Clin Microbiol | year= 1997 | volume= 35 | issue= 12 | pages= 3254-7 | pmid=9399529 | doi= | pmc=PMC230157 | url= }} </ref>. However PCR is found to have low sensitivity and high false positive results in detection of mycobacterium in pericardial fluid<ref name="pmid9399529">{{cite journal| author=Cegielski JP, Devlin BH, Morris AJ, Kitinya JN, Pulipaka UP, Lema LE et al.| title=Comparison of PCR, culture, and histopathology for diagnosis of tuberculous pericarditis. | journal=J Clin Microbiol | year= 1997 | volume= 35 | issue= 12 | pages= 3254-7 | pmid=9399529 | doi= | pmc=PMC230157 | url= }} </ref><ref name="pmid17121764">{{cite journal| author=Reuter H, Burgess L, van Vuuren W, Doubell A| title=Diagnosing tuberculous pericarditis. | journal=QJM | year= 2006 | volume= 99 | issue= 12 | pages= 827-39 | pmid=17121764 | doi=10.1093/qjmed/hcl123 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17121764 }} </ref><ref name="pmid12427503">{{cite journal| author=Lee JH, Lee CW, Lee SG, Yang HS, Hong MK, Kim JJ et al.| title=Comparison of polymerase chain reaction with adenosine deaminase activity in pericardial fluid for the diagnosis of tuberculous pericarditis. | journal=Am J Med | year= 2002 | volume= 113 | issue= 6 | pages= 519-21 | pmid=12427503 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12427503 }} </ref>.
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| *'''[[Adenosine deaminase]](ADA)''' is an enzyme produced by leukocytes. Measurement of ADA levels in pericardial fluid is found to be of diagnostic value in tuberculous pericardial disease<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid16330703">{{cite journal| author=Mayosi BM, Burgess LJ, Doubell AF| title=Tuberculous pericarditis. | journal=Circulation | year= 2005 | volume= 112 | issue= 23 | pages= 3608-16 | pmid=16330703 | doi=10.1161/CIRCULATIONAHA.105.543066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16330703 }} </ref>. ADA levels of ≥40units/liter in pericardial fluid has a good sensitivity and specificity of 87% and 89% respectively<ref name="pmid17121764">{{cite journal| author=Reuter H, Burgess L, van Vuuren W, Doubell A| title=Diagnosing tuberculous pericarditis. | journal=QJM | year= 2006 | volume= 99 | issue= 12 | pages= 827-39 | pmid=17121764 | doi=10.1093/qjmed/hcl123 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17121764 }} </ref>.
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| *Measurement of '''interferon-gamma''' in pericardial fluid is another diagnostic modality with a high sensitivity and specificity of 100%, using a cutoff level of >200pg/L as observed in a series with sample size of 30<ref name="pmid12226030">{{cite journal| author=Burgess LJ, Reuter H, Carstens ME, Taljaard JJ, Doubell AF| title=The use of adenosine deaminase and interferon-gamma as diagnostic tools for tuberculous pericarditis. | journal=Chest | year= 2002 | volume= 122 | issue= 3 | pages= 900-5 | pmid=12226030 | doi= | pmc= | url= }} </ref>. Sensitivity and specificity and positive predective value of 92%, 100% and 100% respectively were noted in another series in South Africa<ref name="pmid17121764">{{cite journal| author=Reuter H, Burgess L, van Vuuren W, Doubell A| title=Diagnosing tuberculous pericarditis. | journal=QJM | year= 2006 | volume= 99 | issue= 12 | pages= 827-39 | pmid=17121764 | doi=10.1093/qjmed/hcl123 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17121764 }} </ref> where prevalence of [[TB]] is high. Further studies with a larger sample size may provide substantial evidence for routine use of this test in diagnosis of TB pericarditis.
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| ===Pericardial biopsy===
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| Pericardial biopsy may cause marked morbidity and prolongation of the hospital stay depending on the approach adopted<ref name="pmid17392991">{{cite journal| author=Reuter H, Burgess LJ, Louw VJ, Doubell AF| title=The management of tuberculous pericardial effusion: experience in 233 consecutive patients. | journal=Cardiovasc J S Afr | year= 2007 | volume= 18 | issue= 1 | pages= 20-5 | pmid=17392991 | doi= | pmc= | url= }} </ref>. Sensitivity of this test in diagnosing [[TB]] ranges between 10-64%<ref name="pmid8665976">{{cite journal| author=Komsuoğlu B, Göldelï O, Kulan K, Komsuoğlu SS| title=The diagnostic and prognostic value of adenosine deaminase in tuberculous pericarditis. | journal=Eur Heart J | year= 1995 | volume= 16 | issue= 8 | pages= 1126-30 | pmid=8665976 | doi= | pmc= | url= }} </ref><ref name="pmid14498251">{{cite journal| author=SCHEPERS GW| title=Tuberculous pericarditis. | journal=Am J Cardiol | year= 1962 | volume= 9 | issue= | pages= 248-76 | pmid=14498251 | doi= | pmc= | url= }} </ref>. Therefore, normal biopsy finding does not exclude TB. The probability of obtaining a definitive bacteriological result is greatest when pericardial fluid and biopsy specimens are examined early in the effusive stage<ref name="pmid13257965">{{cite journal| author=BARR JF| title=The use of pericardial biopsy in establishing etiologic diagnosis in acute pericarditis. | journal=AMA Arch Intern Med | year= 1955 | volume= 96 | issue= 5 | pages= 693-6 | pmid=13257965 | doi= | pmc= | url= }} </ref><ref name="pmid1684009">{{cite journal| author=Strang G, Latouf S, Commerford P, Roditi D, Duncan-Traill G, Barlow D et al.| title=Bedside culture to confirm tuberculous pericarditis. | journal=Lancet | year= 1991 | volume= 338 | issue= 8782-8783 | pages= 1600-1 | pmid=1684009 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1684009 }} </ref>.
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| ==Treatment== | | ==Treatment== |
| ===Anti-tuberculosis chemotherapy===
| | [[Tuberculous pericarditis medical therapy|Medical Therapy]] | [[Tuberculous pericarditis interventions|Interventions]] | [[Tuberculous pericarditis surgery|Surgery]] | [[Tuberculous pericarditis primary prevention|Primary Prevention]] | [[Tuberculous pericarditis secondary prevention|Secondary Prevention]] | [[Tuberculous pericarditis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Tuberculous pericarditis future or investigational therapies|Future or Investigational Therapies]] |
| With the use of antituberculosis chemotherapy, survival rate in tuberculous pericarditis has improved dramatically. Mortality rate in preantibiotic era was 80-90%<ref>Harvey AM, Whitehill MR. Tuberculous pericarditis. Medicine. 1937; 16: 45–94</ref>. At present it is 8-17%<ref name="pmid472922">{{cite journal| author=Desai HN| title=Tuberculous pericarditis. A review of 100 cases. | journal=S Afr Med J | year= 1979 | volume= 55 | issue= 22 | pages= 877-80 | pmid=472922 | doi= | pmc= | url= }} </ref><ref name="pmid7185934">{{cite journal| author=Bhan GL| title=Tuberculous pericarditis. | journal=J Infect | year= 1980 | volume= 2 | issue= 4 | pages= 360-4 | pmid=7185934 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7185934 }} </ref> and 17-34% if associated with [[HIV]]<ref name="pmid10908256">{{cite journal| author=Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A| title=Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. | journal=Heart | year= 2000 | volume= 84 | issue= 2 | pages= 183-8 | pmid=10908256 | doi= | pmc=PMC1760932 | url= }} </ref>. A 2months course of [[isoniazid]], [[pyrazinamide]], [[rifampicin]], and [[ethambutol]] followed by 4months course of [[isoniazid]] and [[rifampicin]] is shown to be effective<ref name="pmid2106816">{{cite journal| author=Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbaro JA| title=A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen. | journal=Ann Intern Med | year= 1990 | volume= 112 | issue= 6 | pages= 407-15 | pmid=2106816 | doi= | pmc= | url= }} </ref>. Short course chemotherapy is beneficial in [[HIV]] infected patients<ref name="pmid7862181">{{cite journal| author=Perriëns JH, St Louis ME, Mukadi YB, Brown C, Prignot J, Pouthier F et al.| title=Pulmonary tuberculosis in HIV-infected patients in Zaire. A controlled trial of treatment for either 6 or 12 months. | journal=N Engl J Med | year= 1995 | volume= 332 | issue= 12 | pages= 779-84 | pmid=7862181 | doi=10.1056/NEJM199503233321204 | pmc= | url= }} </ref>.
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| American Thoracic Society, CDC, and Infectious Diseases Society of America recommends use of '''[[corticosteroids]]'''([[prednisone]]) as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of [[TB#treatment|antituberculosis therapy]]<ref name="pmid12836625">{{cite journal| author=American Thoracic Society. CDC. Infectious Diseases Society of America| title=Treatment of tuberculosis. | journal=MMWR Recomm Rep | year= 2003 | volume= 52 | issue= RR-11 | pages= 1-77 | pmid=12836625 | doi= | pmc= | url= }} </ref>. Following are the dosage recommendations:
| | ==Related Chapters== |
| *'''Adults:''' Prednisone 60 mg/day (or the equivalent dose of prednisolone) given for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and finally 5 mg/day for week 11 (the final week)
| | * [[Pericarditis]] |
| *'''Children:''' doses should be proportionate to their weight, beginning with about 1 mg/kg body weight and decreasing the dose as described for adults.
| | * [[Tuberculosis]] |
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| ===Pericardiectomy===
| | {{WH}} |
| [[Pericardiectomy]] is the surgical removal of the pericardium. It may be adopted in treatment of recurrent [[pericardial efussion]] due to [[TB]], in tuberculous [[constrictive pericarditis]] or if there is no hemodynamic and general improvement after 4-8 weeks following [[TB#treatment|antituberculosis chemotherapy]]<ref name="pmid16330703">{{cite journal| author=Mayosi BM, Burgess LJ, Doubell AF| title=Tuberculous pericarditis. | journal=Circulation | year= 2005 | volume= 112 | issue= 23 | pages= 3608-16 | pmid=16330703 | doi=10.1161/CIRCULATIONAHA.105.543066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16330703 }} </ref>. If it is performed in the early stages of TB pericardial constriction, pericardiectomy has a low mortality rate when compared to advanced stages of the disease where pericardiectomy is poorly tolerated. Mortality rate secondary to this procedure is 3-16%<ref name="pmid7112301">{{cite journal| author=Fennell WM| title=Surgical treatment of constrictive tuberculous pericarditis. | journal=S Afr Med J | year= 1982 | volume= 62 | issue= 11 | pages= 353-5 | pmid=7112301 | doi= | pmc= | url= }} </ref><ref name="pmid3175976">{{cite journal| author=Bashi VV, John S, Ravikumar E, Jairaj PS, Shyamsunder K, Krishnaswami S| title=Early and late results of pericardiectomy in 118 cases of constrictive pericarditis. | journal=Thorax | year= 1988 | volume= 43 | issue= 8 | pages= 637-41 | pmid=3175976 | doi= | pmc=PMC461401 | url= }} </ref>. This surgery should be undertaken under the coverage of antitubercular drugs.
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| Treatment of [[Tuberculous pericarditis#Pathophysiology|effusive constrictive pericarditis]] is challenging because [[pericardiocentesis]] does not relieve the impaired filling of the heart, and surgical removal of the fibrinous exudate coating the visceral pericardium may not be possible. Patients should be started on antitubercular drugs and serial [[echocardiography]] should be performed to monitor the changes of [[pericardium]] and to make a decision regarding its surgical stripping<ref name="pmid16330703">{{cite journal| author=Mayosi BM, Burgess LJ, Doubell AF| title=Tuberculous pericarditis. | journal=Circulation | year= 2005 | volume= 112 | issue= 23 | pages= 3608-16 | pmid=16330703 | doi=10.1161/CIRCULATIONAHA.105.543066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16330703 }} </ref>.
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| ==Approach to patients with suspected tuberculous pericarditis<ref name="pmid16330703">{{cite journal| author=Mayosi BM, Burgess LJ, Doubell AF| title=Tuberculous pericarditis. | journal=Circulation | year= 2005 | volume= 112 | issue= 23 | pages= 3608-16 | pmid=16330703 | doi=10.1161/CIRCULATIONAHA.105.543066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16330703 }} </ref>==
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| {{cquote|
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| #'''Initial evaluation'''
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| #*Chest radiograph may reveal changes suggestive of pulmonary tuberculosis in 30% of cases.
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| #*Echocardiogram: the presence of a large pericardial effusion with frond-like projections, and thick "porridge-like" exudate is suggestive of an exudate but not specific for a tuberculous etiology.
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| #*CT scan and/or MRI of the chest are alternative imaging modalities where available: for evidence of pericardial effusion and thickening (>5 mm) and typical mediastinal and tracheobronchial lymphadenopathy (>10 mm, hypodense centers, matting), with sparing of hilar lymph nodes.
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| #*Culture of sputum, gastric aspirate, and/or urine should be considered in all patients.
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| #*Right scalene lymph node biopsy if pericardial fluid is not accessible and lymphadenopathy is present.
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| #*Tuberculin skin test is not helpful regardless of the background prevalence of tuberculosis.5,50
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| #'''Pericardiocentesis'''
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| #*Therapeutic pericardiocentesis is indicated in the presence of cardiac tamponade.
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| #*Diagnostic pericardiocentesis should be considered in all patients with suspected tuberculous pericarditis, and the following tests should be performed:
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| #*#Direct inoculation of the pericardial fluid into double-strength liquid Kirchner culture medium at the bedside and culture for M tuberculosis.
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| #*#Biochemical tests to distinguish between an exudate and a transudate (fluid and serum protein; fluid and serum LDH).
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| #*#Indirect tests for tuberculous infection: ADA, IFN-, or lysozyme assay.
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| #'''Pericardial biopsy'''
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| #*"Therapeutic" biopsy: as part of surgical drainage in patients with severe tamponade relapsing after pericardiocentesis.
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| #*Diagnostic biopsy: in areas in which TB is endemic, a diagnostic biopsy is not required before commencing empirical antituberculosis treatment. In areas in which TB is not endemic, a diagnostic biopsy is recommended in patients with >3 weeks of illness and without etiologic diagnosis having been reached by other tests.3
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| #'''Empirical antituberculosis chemotherapy'''
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| #*Tuberculosis endemic in the population: trial of empirical antituberculous chemotherapy is recommended for exudative pericardial effusion, after other causes such as malignancy, uremia, and trauma have been excluded.
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| #*Tuberculosis not endemic in the population: when systematic investigation fails to yield a diagnosis of tuberculous pericarditis, there is no justification for starting antituberculosis treatment empirically.}}
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| ==References==
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| {{reflist|2}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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| [[Category:Inflammations]] | | [[Category:Inflammations]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Infectious disease]]
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| | [[Category:Tuberculosis]] |
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