Tuberculous pericarditis: Difference between revisions
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{{Pericarditis}} | {{Pericarditis}} | ||
{{CMG}} '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S. | {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S. | ||
==Overview== | ==Overview== | ||
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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. | :'''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. | ||
Effusive | 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. | ||
==Diagnosis== | ==Diagnosis== | ||
Tuberculous pericarditis has a variable clinical presentation and should be considered in the evaluation of all cases of pericarditis | 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>. | ||
===History and symptoms=== | |||
The patients present with following symptoms: | |||
*[[Fever]] | |||
*[[Weight loss]] | |||
*[[Night sweats]] | |||
*[[Cough]] | |||
*[[breathlessness]] | |||
*[[Chest pain]] which changes with posture | |||
*[[Malaise]] | |||
*Ankle [[edema]] | |||
Frequency and severity of above symptoms varies with stage of infection, the degree of involvement of [[pericardium]], and the degree of extrapericardial infection. | |||
===Physical examination=== | |||
Patients present with [[fever]] and [[cachexia]]. | |||
'''Vitals:''' [[Tachycardia]], [[pulsus paradoxus]] and hypotension(in [[cardiac tamponade]]) | |||
'''Neck:''' [[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]] | |||
'''Chest:''' Pleural dullness, decreased breath sounds, pericardial knock, [[pericardial rub]] and distant [[heart sounds]] | |||
'''Abdomen:''' [[Hepatomegaly]], [[ascites]] | |||
'''Extremities:''' [[Ankle edema]] | |||
===Chest X-ray=== | |||
Pulmonary infiltration by the bacterium may be seen in approximately 32%<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>. | |||
[http://www.radiopaedia.org Image shown below is courtesy of Radiopedia] | |||
[[Image:Tuberculous pericarditis.jpg|thumb|350px|left|14 year old child with tubercular pleural and pericardial effusion. Decortication was performed on left side. Pericardial effusion was aspirated with a wide bore needle on 3 occasions, it reaccumulated immediately.]] | |||
<br clear="left"/> | |||
===Electrocardiogram=== | |||
[[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>. Presence of micro-voltage and [[electrical alternans]] suggests pericardial effusion and tamponade. | |||
[[Image:12leadpericarditis.png|thumb|500px|left|ECG in acute pericarditis showing diffuse ST elevation]][[Image:PulsusAlternans.jpg|thumb|500px|center|Electrical alternans]] | |||
<br clear="left"/> | |||
===Echocardiography=== | |||
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. | |||
'''Below is a video demonstrating echocardiographic features of cardiac tamponade''' | |||
<youtube v=YWVI6rRTIzU/> | |||
===MRI=== | |||
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. | |||
<youtube v=5srXVJdWIAM/> | |||
===Cardiac catheterization=== | |||
*'''Cardiac tamponade:''' Pressures in all four chambers of heart are in equilibrium. | |||
*'''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. | |||
*'''Effusive constrictive pericarditis:''' Cardiac tamponade findings are noted initially. Findings of constrictive pericarditis are unmasked following [[pericardiocentesis]]. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Cardiology]] | |||
[[Category:Diseases involving the fasciae]] | |||
[[Category:Inflammations]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Infectious disease]] | |||
{{WH}} | |||
{{WS}} | |||
Revision as of 20:33, 27 June 2011
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Pericarditis Microchapters |
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Diagnosis |
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Tuberculous pericarditis On the Web |
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American Roentgen Ray Society Images of Tuberculous pericarditis |
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Risk calculators and risk factors for Tuberculous pericarditis |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.
Overview
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)[1]. In 2006 WHO estimated the global prevalence of active TB[2] 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 the inflammation of pericardial sac that encases heart.
Epidemiology and demographics
Tuberculous pericarditis is found in approximately 1-2% of patients with pulmonary tuberculosis[3][4]. It is the most common cause of pericarditis in Africa and other developing countries where TB is a major public health problem[5]. The incidence is increasing rapidly in presence of HIV[6].
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 and one half of the patients were infected with HIV[7]. In contrast, the incidence of tuberculous pericarditis is 4% in developed countries[8].
Natural history and complications
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%[9]. The mortality rate in the modern era is currently 8-17%[10][11] and is 17-34% if the TB is associated with HIV[12].
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 and more common than hypertensive heart disease and cardiomyopathy[13][14]
Constrictive pericarditis is another complication of tuberculous pericarditis occurring in 30-60% of patients despite prompt antituberculosis treatment and the use of corticosteroids[15][8]
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 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 change of pericardium. There are four pathologic stages of involvement:[16][17][18]
- Stage 1: Presence of diffuse fibrin deposition, granulomas and abundant mycobacterium
- Stage 2: Development of serous or serosanguineous pericardial effusion with a predominantly lymphocytic exudate with monocytes and foam cells
- Stage 3: Absorption of effusion with organization of granulomatous caseation and thickening of pericardium secondary to deposition of fibrin and collagen.
- 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.
Effusive constrictive pericarditis[19] 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.
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[8].
History and symptoms
The patients present with following symptoms:
- Fever
- Weight loss
- Night sweats
- Cough
- breathlessness
- Chest pain which changes with posture
- Malaise
- Ankle edema
Frequency and severity of above symptoms varies with stage of infection, the degree of involvement of pericardium, and the degree of extrapericardial infection.
Physical examination
Patients present with fever and cachexia.
Vitals: Tachycardia, pulsus paradoxus and hypotension(in cardiac tamponade)
Neck: Jugular venous distension with a prominent Y descent and Kussmaul's sign
Chest: Pleural dullness, decreased breath sounds, pericardial knock, pericardial rub and distant heart sounds
Abdomen: Hepatomegaly, ascites
Extremities: Ankle edema
Chest X-ray
Pulmonary infiltration by the bacterium may be seen in approximately 32%[20], pleural effusion in 40% to 60%, and cardiomegaly in about 90% of patients with tuberculous pericarditis[21][22].
Image shown below is courtesy of Radiopedia
Electrocardiogram
ECG may show non-specific ST-T–wave changes[15][23]. Characteristic EKG finding of acute pericarditis, PR-segment deviation and diffuse ST-segment elevation are found in only 9-11% of cases[22][23]. Presence of micro-voltage and electrical alternans suggests pericardial effusion and tamponade.
Echocardiography
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.
Below is a video demonstrating echocardiographic features of cardiac tamponade <youtube v=YWVI6rRTIzU/>
MRI
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. <youtube v=5srXVJdWIAM/>
Cardiac catheterization
- Cardiac tamponade: Pressures in all four chambers of heart are in equilibrium.
- 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.
- Effusive constrictive pericarditis: Cardiac tamponade findings are noted initially. Findings of constrictive pericarditis are unmasked following pericardiocentesis.
References
- ↑ Lönnroth K, Raviglione M (2008). "Global epidemiology of tuberculosis: prospects for control". Semin Respir Crit Care Med. 29 (5): 481–91. doi:10.1055/s-0028-1085700. PMID 18810682.
- ↑ 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)
- ↑ Fowler NO (1991). "Tuberculous pericarditis". JAMA. 266 (1): 99–103. PMID 2046135.
- ↑ Larrieu AJ, Tyers GF, Williams EH, Derrick JR (1980). "Recent experience with tuberculous pericarditis". Ann Thorac Surg. 29 (5): 464–8. PMID 7377888.
- ↑ 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.
- ↑ Cegielski JP, Ramiya K, Lallinger GJ, Mtulia IA, Mbaga IM (1990). "Pericardial disease and human immunodeficiency virus in Dar es Salaam, Tanzania". Lancet. 335 (8683): 209–12. PMID 1967676.
- ↑ Reuter H, Burgess LJ, Doubell AF (2005). "Epidemiology of pericardial effusions at a large academic hospital in South Africa". Epidemiol Infect. 133 (3): 393–9. PMC 2870262. PMID 15962545.
- ↑ 8.0 8.1 8.2 Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J (1988). "Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment". J Am Coll Cardiol. 11 (4): 724–8. PMID 3351140.
- ↑ 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.
- ↑ Strang JI (1984). "Tuberculous pericarditis in Transkei". Clin Cardiol. 7 (12): 667–70. PMID 6509811.
- ↑ Hakim JG, Manyemba J (1998). "Cardiac disease distribution among patients referred for echocardiography in Harare, Zimbabwe". Cent Afr J Med. 44 (6): 140–4. PMID 9810393.
- ↑ 15.0 15.1 SCHRIRE V (1959). "Experience with pericarditis at Groote Schuur Hospital, Cape Town: an analysis of one hundred and sixty cases studied over a six-year period". S Afr Med J. 33: 810–7. PMID 14443596.
- ↑ Peel AA (1948). "TUBERCULOUS PERICARDITIS". Br Heart J. 10 (3): 195–207. PMC 481044. PMID 18610109.
- ↑ Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J (1985). "Primary acute pericardial disease: a prospective series of 231 consecutive patients". Am J Cardiol. 56 (10): 623–30. PMID 4050698.
- ↑ Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
- ↑ Sagristà-Sauleda J, Angel J, Sánchez A, Permanyer-Miralda G, Soler-Soler J (2004). "Effusive-constrictive pericarditis". N Engl J Med. 350 (5): 469–75. doi:10.1056/NEJMoa035630. PMID 14749455.
- ↑ Fowler NO, Manitsas GT (1973). "Infectious pericarditis". Prog Cardiovasc Dis. 16 (3): 323–36. PMID 4593515.
- ↑ Reuter H, Burgess LJ, Doubell AF (2005). "Role of chest radiography in diagnosing patients with tuberculous pericarditis". Cardiovasc J S Afr. 16 (2): 108–11. PMID 15915278.
- ↑ 22.0 22.1 Rooney JJ, Crocco JA, Lyons HA (1970). "Tuberculous pericarditis". Ann Intern Med. 72 (1): 73–81. PMID 5410398.
- ↑ 23.0 23.1 Smedema JP, Katjitae I, Reuter H, Burgess L, Louw V, Pretorius M; et al. (2001). "Twelve-lead electrocardiography in tuberculous pericarditis". Cardiovasc J S Afr. 12 (1): 31–4. PMID 11447490.