Pericarditis purulenta por mycobacterium tuberculosis y streptococcus pneumoniae: revisión del tema, a propósito de un caso / Purulent pericarditis due to mycobacterium tuberculosis and streptococcus pneumoniae: case report and review

La pericarditis purulenta es una patología poco frecuente pero que conlleva alta mortalidad. En la era pre antibióticos, se observaba en pacientes con neumonía complicada y las cocáceas gram positivas eran los gérmenes frecuentemente involucrados. Por otro lado, la pericarditis tuberculosa representa el 1% del total de casos de tuberculosis, aunque es frecuente zonas endémicas, principalmente asociada a la infección por el virus de la inmunodeficiencia humana (VIH). Presentamos el caso de un paciente de 19 años, en situación calle, infectado con VIH, con diagnóstico de pericarditis purulenta, donde se demostró la co-infección de Mycobacterium tuberculosis y Streptecoccus pneumoniae en el pericardio. La pericarditis purulenta polimicrobiana es poco frecuente y la co-infección por los gérmenes mencionados es anecdótica. A pesar del tratamiento antimicrobiano, el aseo quirúrgico, los esteroides y la fibrinolisis intrapericárdica, esta patología tiene un pronóstico ominoso, en parte, debido a la condición basal de los enfermos que la padecen.

Purulent pericarditis is a rare disease with a high mortality rate. In the pre-antibiotic era it was observed as a complication in patients with pneumonia. Gram-positive coccaceae were the most commonly implicated bacteria. Tuberculous pericarditis represents 1% of all tuberculosis (TBC) cases, although it is common in endemic areas, associated with human immunodeficiency virus (HIV) infection. We present the case of a 19-year-old homeless, admitted with HIV and malnutrition, diagnosed with purulent pericarditis. Mycobacterium tuberculosis and Streptococcus pneumoniae were found as a cause of purulent pericarditis. Polymicrobial purulent pericarditis is a rare condition and co-infection with the bacteria previously mentioned is merely anecdotal. Despite antimicrobial treatment, surgical management, steroids, and intrapericardial fibrinolysis, this pathology has an ominous prognosis, due in part to the pre-existing condition of these patients.

Pericarditis tuberculosa: una manifestación extrapulmonar infrecuente de TBC / Tuberculous pericarditis an infrequent extrapulmonary manifestation of TB

Extrapulmonary tuberculosis (TB) contributes to 15% of total cases, representing a great diagnostic and therapeutic challenge. Pericardial involvement is present in 1 to 2% of TB patients and is considered an unusual presentation form of TB. We report a 67-year-old male presenting with fever and progressive dyspnea. A chest CAT scan showed a bilateral pleural effusion and an extensive pericardial effusion. An echocardiogram showed signs of tamponade. Therefore, an emergency pericardiectomy was performed. The pathological report of pericardial tissue showed caseating necrosis and its Koch culture was positive. The patient was treated with anti-tuberculous drugs with a favorable evolution.

Polisserosite de Concato: uma doença rara ou pouco conhecida? / Concato's disease: a rare or a little known condition?

Polisserosite consiste na inflamação das serosas (pericárdio, pleurae peritônio) com efusão. Na polisserosite de Concato, além das manifestações inflamatórias das serosas, ocorre pericardite com espessamento dos folhetos do pericárdio, podendo levar a um quadro de pericardite constritiva. Justifica-se este estudo ao considerarmos que a etiologia das serosites são muitas; por isso, há necessidade de melhor estudá-las e difundi-las no meio acadêmico. Nesse sentido, propomo-nos a rever a literatura, por meio de levantamento bibliográfico, de pesquisa em rede e literatura atualizada sobre o tema abordado. Deste modo, pretendemos melhor elucidar a etiopatogenia da doença de Concato, dada a importância do diagnóstico precoce, combinado ao tratamento adequado, na prevenção de consequências indesejáveis e fatais. O principal objetivo desta revisão é meramente acadêmico, pois há um desconhecimento muito grande desta forma de apresentação de tal doença no meio médico. Acreditamos que, com este estudo de revisão, poderemos contribuir para a conscientização e efetivação do diagnóstico precoce da patologia estudada, evitando complicações e, assim, promover: saúde, multiplicação e difusão do conhecimento adquirido.

Polyserositis is the inflammation of serous membranes (pericardium, pleura and peritoneum) with effusion. In Concato’s disease, in addition to chronic inflammatory manifestations of serous membranes, there occurs pericarditis with thickening of pericardium leasflets, which may lead to a picture of constrictive pericarditis. This study is justified by the multiple etiological factors that may lead to serosites, and the need to further study and publish study results. In this sense, a review was proposed by making a literature survey using network research and current literature available on the topic for the purpose of elucidating the etiopathogenesis of Concato’s disease, given the importance of an early diagnosis, in association with the appropriate treatment, in the prevention of undesirable or even fatal consequences. The aim of this review is academic, inasmuch as there is lack of medical knowledge on the manifestations of this condition. By doing this, we aim to contribute to developing an awareness of the importance of an early diagnosis of this pathology, thus avoiding complications and promoting health and the propagation of acquired knowledge.

Polymicrobial Purulent Pericarditis Probably caused by a Broncho-Lymph Node-Pericardial Fistula in a Patient with Tuberculous Lymphadenitis / 감염과화학요법

Purulent pericarditis is a rare condition with a high mortality rate. We report a case of purulent pericarditis subsequently caused by Candida parapsilosis, Peptostreptococcus asaccharolyticus, Streptococcus anginosus, Staphylococcus aureus, Prevotella oralis, and Mycobacterium tuberculosis in a previously healthy 17-year-old boy with mediastinal tuberculous lymphadenitis. The probable route of infection was a bronchomediastinal lymph node-pericardial fistula. The patient improved with antibiotic, antifungal, and antituberculous medication in addition to pericardiectomy.

Pericarditis tuberculosa / Tuberculous pericarditis

La tuberculosis sigue siendo una de las principales causas de morbilidad y mortalidad en el mundo. Su forma extrapulmonar representa hasta el 20 % de los casos. Se ha estimado que el compromiso pericárdico en esta enfermedad se presenta en 1 a 4 % de los pacientes diagnosticados. Su mortalidad alcanza el 90 % si no se diagnostica y se trata adecuadamente; este porcentaje se reduce a 12 % con el diagnóstico y el tratamiento oportunos. Se presenta el caso de una paciente de 55 años, hospitalizada durante dos semanas con síntomas constitucionales, fiebre intermitente, tos seca, dolor pleurítico y algunos síntomas de falla cardiaca. En los estudios de imaginología (radiografía y ecografía de tórax) se encontró derrame pleural bilateral de 300 ml en el lado derecho y de 1.000 ml en el izquierdo, así como derrame pericárdico de 500 ml. Las baciloscopias directas de los líquidos pleural y pericárdico, así como en esputo, fueron negativas, al igual que la proteína C reactiva (PCR); sin embargo, el cultivo del líquido pericárdico en medio de Löwenstein-Jensen fue positivo para Mycobacterium tuberculosis . El resultado de la prueba de PPD ( Purified Protein Derivative ) fue de 23 mm; una vez iniciado el tratamiento conjugado con isoniacida, rifampicina, etambutol y pirazinamida, se presentó una mejoría rápida del cuadro clínico que persistió hasta que se le dio de alta. La pericarditis tuberculosa puede considerarse como una manifestación infrecuente de la tuberculosis, con una morbilidad elevada y una mortalidad considerable, cuya probabilidad disminuye si hay un diagnóstico oportuno y se instaura un tratamiento efectivo temprano. Aunque se han sugerido varios criterios diagnósticos para la pericarditis tuberculosa, su diagnóstico definitivo puede implicar varios desafíos técnicos.

Tuberculosis remains a major cause of morbidity and mortality worldwide, and the extrapulmonary presentation represents up to 20% of this disease. The pericardial compromise of this disease has been estimated between 1% and 4% of diagnosed patients. This presentation may have a mortality rate as high as 90% without proper treatment and diagnosis, dropping to 12% with timely diagnosis and treatment. We present the case of a 55 year-old female patient hospitalized for two weeks with constitutional symptoms, intermittent fever, dry cough, pleuritic pain and some symptoms of heart failure. The imaging studies (chest x-rays and ultrasound), revealed bilateral pleural effusion: 300 cc on the right side, 1,000 cc on the left side, and 500 cc of pericardial effusion. Direct bacilloscopy of the pleural fluid, the pericardial fluid and the sputum were negative, as well as the C-reactive protein (CRP); however, the Löwenstein-Jensen culture of the pericardial fluid was positive for Mycobacterium tuberculosis . The result of the purified protein derivative (PPD) test showed a 23 mm swelling, and after quadruple therapy her clinical condition rapidly improved until final discharge. Tuberculous pericarditis can be considered as a rare manifestation of tuberculosis, with high morbidity and significant mortality which decrease with effective early diagnosis and treatment. Although several diagnostic criteria for tuberculous pericarditis have been suggested, a definitive diagnosis may suppose several technical challenges.

Interferon-gamma Release Assay Using Pericardial Fluid and Peripheral Blood for the Diagnosis of Tuberculous Pericarditis: A Case Report

Here, we report a case in which the rapid diagnosis of tuberculous pericarditis was made using Mycobacterium tuberculosis (MTB)-specific interferon-gamma release assay on peripheral blood and pericardial effusion. Acid-fast bacilli staining, mycobacterial culture, and nucleic acid amplification targeting MTB using pericardial fluid were negative. However, elevated adenosine deaminase (ADA) activity in pericardial fluid and interferon-gamma release assay positivity in both pericardial fluid and peripheral blood indicated the presence of tuberculous pericarditis. After anti-tuberculous and steroid treatment, the patient's clinical symptoms improved, and pericardial effusion has not reoccurred.

Pericarditis constrictiva tuberculosa: reporte de un caso y revisión de la literatura / Tuberculous constrictive pericarditis: case report and literature review

La pericarditis tuberculosa (PT) representa una rara manifestación extrapulmonar de tuberculosis (TBC), que se encuentra en aproximadamente el 1 por ciento de las autopsias por TBC y 1-2 por ciento de casos de TBC pulmonar, estando su presentación estrechamente asociado con la infección por VIH. El compromiso pericárdico ocurre habitualmente por diseminación linfática retrógrada o diseminación hematógena desde un foco pulmonar primario, pudiendo clínicamente manifestarse como derrame pericárdico, pericarditis constrictiva o un patrón mixto. El presente trabajo, describe los hallazgos clínicos y morfológicos de un caso de PT en un sujeto inmunocompetente de 78 años, con diagnóstico de PT constrictiva efectuado en el Hospital Hernán Henríquez Aravena de Temuco.

Tuberculous pericarditis (TP) is a rare manifestation of extrapulmonary tuberculosis (TBC), found in approximately 1 percent of autopsies by TB and 1-2 percent of cases of pulmonary TB, while his presentation closely associated with the HIV infection. The pericardial involvement usually occurs by retrograde lymphatic spread or hematogenous spread from a primary pulmonary focus, which may clinically manifest as pericardial effusion, constrictive pericarditis or a mixed pattern. This paper describes the clinical and morphological findings of a TP case in an 78-year old immunocompetent patient, with constrictive TP diagnosed made in the Hospital Hernán Henríquez Aravena in Temuco.

Tuberculous Pericarditis Presenting as Multiple Free Floating Masses in Pericardial Effusion

Pericarditis is a rare manifestation of tuberculosis (Tb) in children. A 14-yr-old Korean boy presented with cardiac tamponade during treatment of pulmonary tuberculosis. He developed worsening anemia and persistent fever in spite of anti-tuberculosis medications. Echocardiography found free floating multiple discoid masses in the pericardial effusion. The masses and exudates were removed by pericardiostomy. The masses were composed of pink, amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes with numerous acid-fast bacilli, which were confirmed as Mycobacterium species by polymerase chain reaction. The persistent fever and anemia were controlled after pericardiostomy. This is the report of a unique manifestation of Tb pericarditis as free floating masses in the effusion with impending tamponade.

The Ratio Between the Percentage of Lymphocytes and Glucose Levels in Pericardial Fluid as a Method to Diagnose Tuberculous Pericarditis / 대한내과학회지

BACKGROUND/AIMS: Adenosine deaminase (ADA) is a valuable biochemical marker for pericardial effusion (PE) and may be useful for diagnosing tuberculous pericarditis (TPE) in patients with PE. However, no definite cut-off or borderline values for ADA currently exist to distinguish TPE from other PE etiologies. In this study, we identified other useful parameters and characterized their relationship with ADA as a method for diagnosing TPE. METHODS: From June 2004 to November 2011, 42 patients underwent pericardiocentesis due to moderate or severe PE, as confirmed by echocardiography or chest computed tomography (CT). Patients were subdivided into TPE and non-TPE (NTPE) groups. We analyzed ADA (p) (the pericardial ADA) and %Lymph (p)/Glucose (p) (the ratio between the percentage of lymphocytes and glucose levels in PE). RESULTS: We defined the cut-off value of ADA (p) as 48.5 IU/L, and that of %Lymph (p)/Glucose (p) as 0.678%.dL/mg. In a multivariate logistic regression analysis, an odds ratio (OR) of 44.24 and a 95% confidence interval (CI) of 2.85-686.97 were observed in patients with an ADA (p) > or = 48.5 IU/L (p = 0.023). An OR of 20.39 and a 95% CI of 1.06-392.93 were observed in patients with a %Lymph (p)/Glucose (p) > or = 0.678%.dL/mg (p = 0.046). The combination of ADA (p) and %Lymph (p)/Glucose (p) had a higher positive predictive value (PPV, 80.0%) and specificity (Sp, 93.8%) than either ADA (p) (PPV, 47.4%; Sp, 68.8%) or %Lymph (p)/Glucose (p) (PPV, 69.2%; Sp, 87.5%) alone. CONCLUSIONS: %Lymph (p)/Glucose (p) is a useful parameter for distinguishing TPE from other pericardial diseases if combined with an ADA (p) > or = 48.5 IU/L.

Appropriateness of Adenosine Deaminase-Guided Management for Patients with Pericardial Effusion / 대한내과학회지

BACKGROUND/AIMS: The prognostic impact of empirical anti-tuberculous management according to adenosine deaminase (ADA) levels in patients exhibiting pericardial effusion (PE) has not been established. We evaluated the appropriateness of ADA-guided anti-tuberculous medication for patients with PE. METHODS: From 2001 to 2010, 47 patients with PE and who were diagnosed with either tuberculous pericarditis (TbP) or idiopathic pericarditis (IP) were enrolled. The diagnosis of definite TbP was made by the presence of Tb bacilli or caseous granuloma in pericardial tissue or effusion. The diagnosis of probable TbP was made by the presence of one or more of the following: (1) elevated ADA (> or = 40 IU/L) in pericardial fluid, (2) positive Tb interferon test, or (3) extracardiac presence of Tb. All clinical information was collected by medical record review and telephone contact. RESULTS: Among the 47 patients with PE, 12 were diagnosed with definite TbP; 17, with probable TbP; and 18, with IP. The mean ADA level was significantly higher in patients with definite TbP than in patients with IP (74.97 +/- 36.79 vs. 20.14 +/- 7.39 IU/L; p < 0.001). The optimal ADA cutoff value for diagnosis of definite TbP was 64 IU/L. The median follow-up time was 12.1 months (range, 0.17-100 months). In patients with low levels of ADA (< 40 IU/L), the incidence of death or recurrence did not different between patients who were prescribed anti-tuberculous medication and those who were not. CONCLUSIONS: The ADA level in pericardial fluid was useful for making a rapid diagnosis of tuberculous pericarditis. Even in tuberculosis-endemic areas, patients with ADA < 40 IU/L may have a good prognosis without empirical anti-tuberculous treatment.

Pericarditis y pericardiectomía: experiencia en el hospital r.a. calderón guardia, 2003-2010 / Pericarditis and pericardiectomy: the 2003-2010 hospital r.a. calderon guardia experience

Intoducción: la pericarditis puede presentarse como un derrame pericárdico o como constricción pericárdica y en un peque¤o porcentaje de pacientes, ocurren ambos. Las causas son variables y en ocaciones, la resolución es quirúrgica. El propósito de este reporte es mostrar la experiencia quirúrgica acumulada en nuestro centro durante los últimos 7 años. Métodos: Se revisaron los expedientes clínicos de todos los pacientes quienes se les practicó una intervención pericárdica primaria por derrame pericárdico o pericarditis constrictiva en el Hospital Rafael A. Calderón Guardia en San José, Costa Rica, desde octubre de 2003 a setiembre de 2010. Se excluyeron aquellos individuos con derrame pericárdico secundario a sobreanticoagulación, cirugía cardiaca reciente, trauma torácico o trasudados secundarios a patología sistémica. Resultados: Se incluyeron 19 pacientes, 11 hombres y 8 mujeres, 16 con derrame pericárdico y 3 con pericarditis constrictiva. Treinta y siete por ciento de los pacientes tuvieron cuadros de pericarditis inespecífica, 32 por ciento tenían una pericarditis infecciosa, y 26 por ciento tuvieron pericarditis de origen neoplástico, 1 tuvo una pericarditis quilosa. Tres enfermos eran portadores de virus de inmunodeficiencia humana, 2 con pericarditis tuberculosa y 1 con pericarditis inespecífica. En general los pacientes con derrame hemodinámicamente importante fueron abordados mediante ventana subxifoidea y en los casos de contrucción se utilizó pericardiectomía. Solo un paciente falleció en esta serie, por síndrome de bajo gasto postoperatorio. Conclusión: Se revisa el manejo clínico, quirúrgico y anestésico de estos enfermos y se analiza el síndrome de bajo gasto, que puede ocurrir en algunos de ellos al drenar el líquido o al descomprimir el corazón.

Introduction: Pericarditis may present with a pericardial effusion of variable size, inflammation alone or constrictivepericarditis. In a small percentage of cases, effusion and constriction can coincide. The causes of pericarditis are varied andon some occasions, surgery is recommended. This article is a report of our surgical experience in patients with pericarditisover the last 7 years at the R.A. Calderón Guardia Hospital.Methods. The medical records of 19 consecutive individuals seen from 2003 to 2010, with pericardial effusion orconstrictive pericarditis who required a surgical procedure were reviewed. We excluded those individuals who had ahemorrhagic pericardial effusion associated with over anticoagulation and other patients with systemic pathology orrecent cardiac surgery.Results. There were 11 males and 8 females patients. A total of 16 patients had a pericardial effusion and 3 had constrictivepericarditis. Nonspecific pericarditis was seen in 37% of the patients, 32% had infectious pericarditis, 26% had malignantpericarditis, and 1 had chylous pericarditis. Three patients had human immunodeficiency virus, 2 had tuberculouspericarditis, and 1 had nonspecific pericarditis. Only 1 patient died in association with the surgery.Conclusion. The clinical, surgical and anesthesiological management of patients with pericarditis is reviewed. A low outputsyndrome seen after pericardial decompression is also described and discussed.

A Newly Developed Pericardial Tuberculoma During Antituberculous Therapy

Tuberculosis generally affects the respiratory tract. In developing nations, the pericardium is the most common location of extrapulmonary tuberculosis; however, tuberculous pericarditis rarely appears as a localized mass or tuberculoma. We present here a case of a 62-year-old woman with pericardial tuberculoma. She had a history of effusive tuberculous pericarditis and drainage. Because she had taken regular medication over a period of six months, the pericardial mass with an adjacent lung nodule newly detected on the chest radiogram was initially suspected of being invasive lung cancer. Prior to pathologic confirmation, precise information from imaging tests, including computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography are helpful when making decisions regarding which methods should be used for surgical approach and treatment. Through imaging, our case showed typical features of pericardial tuberculoma and a favorable clinical course after two months with a change in antituberculous therapy.

A Case of Tuberculous Pericardial Abscess Mimicking Thymic Carcinoma / 결핵및호흡기질환

We report here an unusual case of pericardial tuberculoma that was misdiagnosed as thymic carcinoma on an imaging study. A 48-year-old woman was referred for evaluation of an anterior mediastinal mass. Computed tomography (CT) scans of the chest displayed cystic masses mimicking thymic carcinoma at the anterior mediastinum. Pericardiotomy and surgical drainage of the cystic masses were done, and pathologic examination of the excised pericardial specimen showed a chronic granulomatous inflammation with necrosis, compatible with tuberculosis. Acid-fast bacilli were also identified in the specimen. After treatment with anti-tuberculosis drugs and steroids, the patient showed clinical improvement. Although tuberculous pericarditis usually presents as pericardial effusion or constrictive pericarditis, it can also present as a pericardial mass mimicking thymic carcinoma on CT. Therefore, we suggest that tuberculous pericardial abscess should be included in the differential diagnosis of a mediastinal mass in Korea, with intermediate tuberculosis prevalence.