1. Interesting Case Rounds
Nicole Kirkpatrick
February 7, 2008

2. Case
25 y.o. first nations male
CC: RUQ pain and SOB

3. HPI SOBOE X 4 weeks, gradually worsening Cough RUQ pain X 3 days
Constant pain, non-radiating
No nausea, vomiting or diarrhea
No peripheral edema, no orthopnea
No recent travel, no sick contacts
Not immunocompromised
Fever, night sweats and weight loss

4. HPI PMH - healthy PSH - none Medications - none Allergies - none
Smoker
ETOH -15 beers/w
Marijuana use

5. Vital signs
HR 105
BP 110/80
RR 25
T 38
SpO2 98% on R/A

6. Physical exam Thin, no icterus noted CVS
JVP ~8cm, does not vary with respiration
Normal S1, S2, no extra HS appreciated
Decrease in SBP of 8mmHg on inspiration
Mild peripheral edema
RESP
Clear
ABD
Soft
Liver edge palpable ~4 cm below CM
Tender in RUQ
Spleen not palpable
No peritoneal findings
No shifting dullness

7. Investigations?

8. Investigations Blood work Hb normal WBC slightly elevated
Normal electrolytes
Normal renal function
ALT slightly elevated

9. Investigations
ECG
Sinus tachycardia
Low voltage

10. Investigations
CXR

11. Chest X-ray

12. Thoughts?

13. Differential Infection
Viral (coxsackie A,B, HIV, Hepatitis), Bacterial (pneumococcus, streptococcus, staphylococcus, TB,Neisseria,Legionnella), Fungal (histoplasmosis, coccidioidomycosis), Parasitic
Inflammation
RA, SLE, AS, Scleroderma, ARF, Wegner’s
Metabolic
Uremia, Hypothyroidism
Neoplastic
Primary or Metastatic (Lung, Breast, Lymphoma, Leukemia)
Drug-related
Procainamide, INH, Hydralazine, Minoxidil, Phenytoin)
Irradiation
Trauma
Dressler’s

14. Initial management

15. Management Transferred to larger centre for definitive diagnosis ECHO
Pericardiocentesis
Pericardial biopsy

16. Diagnosis
Tuberculous pericarditis

17. Objectives Review TB TB pericarditis Epidemiology Presentations
Diagnosis
Treatment

18. Mycobacterium tuberculosis

19. Tuberculosis Mycobacterium tuberculosis Other Mycobacterium spp.
Aerobic, non-spore forming, slow growing bacillus
Humans are the only reservoir
Other Mycobacterium spp.

20. World Incidence of TB Incidence per 100,000 pop / year > 300
< 24
No data
Source: 2005 WHO (maps.maplecroft.com)

21. Tuberculosis Primary infection Latent TB Reactivation
Infected through droplet transmission
Host defenses kill bacteria and prevent active disease
Latent TB
Due to bacilli that survive host defenses and are carried to LN where they can survive for years
Reactivation
Occurs when host immune system is not capable of containing foci of latent infection

22. Tuberculosis and HIV Increased risk of:
Primary disease becoming active infection
Reactivation
5-10% per year
Extrapulmonary TB

23. WHO Estimates of TB (2005) Incidence: 8.8 million worldwide
Canada
5 cases / 100,000 (1616 total)
Prevalence: 14 million

24. Tuberculous Pericarditis
Leading cause of pericarditis in African and Asia
Occurs in 1-2% of patients with pulmonary TB
Commonly due to reactivation with no obvious primary focus
Accounted for 70% of cases referred for diagnostic pericardiocentesis in SA series
4% in the developed world

25. Tuberculous Pericarditis
Pericardium involved via
Retrograde lymphatic spread
Peritracheal, peribronchial, mediastinal LN
Contiguous spread from adjacent lesion
Lung, pleurae, ribs, diaphragm, peritoneum
Hematogenous spread

26. Tuberculous Pericarditis
Four pathological stages
DRY
Isolated granulomas
EFFUSIVE
Serosanginous effusion with lymphocytic exudate
ABSORPTIVE
Absorption of effusion and resolution of symptoms without treatment
CONSTRICTIVE
Fibrosis of visceral and parietal pericardium
+/- effusion

27. Tuberculous Pericarditis
Mortality
80-90% in pre-antibiotic era
8-17% in HIV negative patients
17-34% in HIV positive patients

28. Tuberculous Pericarditis
Three clinical presentations
Pericardial effusion (80%)
Constrictive pericarditis (5%)
30-60% of patients progress to constrictive pericarditis
Effusion-constriction (15%)

29. Tuberculous Pericarditis
Effusion
Bacilli penetrate pericardium
Antigens on bacilli initiate a delayed hypersensitivity reaction
Lymphocytes release cytokines that activate MP and induce granuloma formation
Often few bacilli found in pericardial fluid

30. Tuberculous Pericarditis
Symptoms
Cough
Dyspnea CP
Night sweats
Orthopnea
Weight loss
Signs
Tachycardia
Fever
JVD
HSM
Ascites
Edema

31. Tuberculous Pericarditis
Effusion
Tamponade
Pulsus paradoxus
Friction rub
Indistinct apical impulse
Distant heart sounds
Constriction
Kussmaul’s
Pericardial knock
Effusive-constriction
Often apparent when RA pressure remains elevated after fluid removal

32. Diagnosis Can be challenging Consider in patients
Pericarditis that does not resolve
From TB endemic areas
Work or Travel in endemic areas
High risk populations

33. Diagnosis ECG Non specific changes Low QRS voltage
Diffuse T wave inversion
Electrical alternans if large effusion
Minority can present with acute ST and PR changes of acute pericarditis
CXR
May show pulmonary lesion
Increased cardiac silhouette with pericardial effusion
Pleural effusion
Pulmonary venous congestion rare

34. Diagnosis ECHO Effusion Constriction Fibrinous strands
RA compression, RV diastolic collapse, abN respiratory variation in tricuspic and mitral flow velocities, dilated venae cavae
Constriction
Pericardial thickening
Abnormal ventricular septal movement

35. Diagnosis Tuberculin Skin Test
Can be negative in up to 30% due to anergy

36. Diagnosis Pericardiocentesis and analysis of fluid Exudative effusion
AFB on smear (40-60%)
Culture
Other
PCR for Mycobacterium DNA
Elevated adenosine deaminase
Interferon gamma using ELISA

37. Diagnosis Pericardial biopsy Stain tissue for AFB Histology
Granulomatous inflammation

38. Treatment Anti-tuberculous treatment
Early studies with Streptomycin showed decreased mortality and progression to constriction
INH, Rifampin, Pyrazinamide, Ethambutol X 2M
INH, Rifampin X 4M

39. Quiz Multi-drug resistant TB (MDR-TB)
Resistant to INH and RIFAMPIN
Extensively drug resistant TB (XDR-TB)
Resistant to INH and RIFAMPIN and to 3 of the 6 main classes of second line agents
Aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine, paraaminosalicyclic acid

40. Treatment Steroids Still controversial
Decrease mortality, need for pericardiectomy

41. Treatment Pericardiectomy
After initiation of anti-tuberculous treatment

42. Back to the case Found to have Effusive-Constrictive Pericarditis
TB skin test negative
Started on anti-tuberculous treatment
Underwent pericardiectomy
Technically difficult, not able to completely remove pericardium
On-going difficulty with HF
Work-up for transplant

43. Questions or Comments?

44. References
Cherian, G. (2004). "Diagnosis of tuberculous aetiology in pericardial effusions." Postgrad Med J 80(943):
Mayosi, B. M., L. J. Burgess, et al. (2005). "Tuberculous pericarditis." Circulation 112(23):
Mayosi, B. M., C. S. Wiysonge, et al. (2006). "Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry." BMC Infect Dis 6: 2.
Nardell, E. A., D. Fan, et al. (2004). "Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case A 30-year-old woman with a pericardial effusion." N Engl J Med 351(3):
Strang, J. I., A. J. Nunn, et al. (2004). "Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up." Qjm 97(8):
Syed, F. F. and B. M. Mayosi (2007). "A modern approach to tuberculous pericarditis." Prog Cardiovasc Dis 50(3):
Wragg, A. and J. I. Strang (2000). "Tuberculous pericarditis and HIV infection." Heart 84(2):
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