Fungal esophagitis associated with tuberculous pericarditis in an human immunodeficiency virus-positive patient: a case report.

BACKGROUND: Opportunistic infections are frequent in people living with the human immunodeficiency virus who either do not have access to antiretroviral therapy (ART) or use it irregularly. Tuberculosis is the most frequent infectious disease in PLHIV and can predispose patients to severe fungal infections with dire consequences. CASE PRESENTATION: We describe the case of a 35-year-old Brazilian man living with human immunodeficiency virus (HIV) for 10 years. He reported no adherence to ART and a history of histoplasmosis with hospitalization for 1 month in a public hospital in Natal, Brazil. The diagnosis was disseminated Mycobacterium tuberculosis infection. He was transferred to the health service in Recife, Brazil, with a worsening condition characterized by daily fevers, dyspnea, pain in the upper and lower limbs, cough, dysphagia, and painful oral lesions suggestive of candidiasis. Lymphocytopenia and high viral loads were found. After screening for infections, the patient was diagnosed with tuberculous pericarditis and esophageal candidiasis caused by Candida tropicalis. The isolated yeasts were identified using the VITEK 2 automated system and matrix-assisted laser desorption/ionization time-of-flight-mass spectrometry. Antifungal microdilution broth tests showed sensitivity to fluconazole, voriconazole, anidulafungin, caspofungin, micafungin, and amphotericin B, with resistance to fluconazole and voriconazole. The patient was treated with COXCIP-4 and amphotericin deoxycholate. At 12 days after admission, the patient developed sepsis of a pulmonary focus with worsening of his respiratory status. Combined therapy with meropenem, vancomycin, and itraconazole was started, with fever recurrence, and he changed to ART and tuberculostatic therapy. The patient remained clinically stable and was discharged with clinical improvement after 30 days of hospitalization. CONCLUSION: Fungal infections should be considered in patients with acquired immunodeficiency syndrome as they contribute to worsening health status. When mycoses are diagnosed early and treated with the appropriate drugs, favorable therapeutic outcomes can be achieved.

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

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.

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.

[Tuberculous pericarditis]. / Pericarditis tuberculosa.

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.

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.

Relato de caso: pericardite tuberculosa, um desafio diagnóstico / Case report: tuberculous pericarditis, a diagnostic challeng

O trabalho de conclusão de curso proposto consiste em um relato de caso de um paciente acometido por uma complicação rara da tuberculose, a pericardite. Dessa forma o principal objetivo do mesmo é alertar o clínico para a importância do diagnóstico precoce da tuberculose pericárdica entre as causas de pericardites agudas devido sua alta morbimortalidade. HDA: Paciente J.C.S.B, masculino, 29 anos, admitido com dor abdominal, náuseas e vômitos há 2 dias. Negava comorbidades. Ao exame físico apresentava-se em regular estado geral, ausculta cardíaca sem alterações, abdome com hepatomegalia. Exames laboratoriais evidenciavam hemograma com leucocitose e desvio à esquerda; função renal e hepática alteradas e urina I de caráter infeccioso. Iniciado ceftriaxone empírico. O ECG com supradesnivelamento de segmento ST difuso. Tomografia computadorizada de tórax e abdome com acentuado derrame pericárdico e moderados derrame pleural bilateral e ascite. Ecocardiograma revelou derrame pericárdico importante (560 ml) com presença de fibrina e colapso de átrio e ventrículo direitos. Paciente evoluiu durante a internação com sinais de instabilidade clínica, sendo indicada pericardiocentese por toracotomia subxifóidea, que evidenciou exsudato. Houve necessidade de drenagem em centro cirúrgico por recidiva dos derrames pleural e pericárdico. A biópsia de pericárdio demonstrou pericardite fibrino-leucocitária em organização. Líquido pericárdico com ADA de 56,7U/L. Iniciado tratamento para tuberculose com melhora clínica. A associação de um quadro clínico de pericardite aguda com o valor do ADA no líquido pericárdico acima do valor de referência e a melhora clínica com a instituição do tratamento direcionado culminou no diagnóstico presuntivo de pericardite tuberculosa.

Relato de caso: pericardite tuberculosa, um desafio diagnóstico / Case report: tuberculous pericarditis, a diagnostic challenge

O trabalho de conclusão de curso proposto consiste em um relato de caso de um paciente acometido por uma complicação rara da tuberculose, a pericardite. Dessa forma o principal objetivo do mesmo é alertar o clínico para a importâcia do diagnóstico precoce da tuberculose pericárdica entre as causas de pericardites agudas devido sua alta morbimortalidade. HDA: Paciente J.C.S.B, masculino, 29 anos, admitido com dor abdominal, náuseas e vômitos há 2 dias. Negava comorbidades. Ao exame físico apresentava-se em regular estado geral, ausculta cardíaca sem alterações, abdome com hepatomegalia. Exames laboratoriais evidenciavam hemograma com leucocitose e desvio à esquerda; função renal e hepática alteradas e urina I de caráter infeccioso. Iniciado ceftriaxone empírico. O ECG com supradesnivelamento de segmento ST difuso. Tomografia computadorizada de tórax e abdome com acentuado derrame pericárdico e moderados derrame pleural bilateral e ascite. Ecocardiograma revelou derrame pericárdico importante (560 ml) com presença de fibrina e colapso de átrio e ventrículo direitos. Paciente evoluiu durante a internação com sinais de instabilidade clínica, sendo indicada pericardiocentese por toracotomia subxifóidea, que evidenciou exsudato. Houve necessidade de drenagem em centro cirúrgico por recidiva dos derrames pleural e pericárdico. A biópsia de pericárdio demonstrou pericardite fibrino-leucocitária em organização. Líquido pericárdico com ADA de 56,7U/L. Iniciado tratamento para tuberculose com melhora clínica. A associação de um quadro clínico de pericardite aguda com o valor do ADA no líquido pericárdico acima do valor de referência e a melhora clínica com a instituição do tratamento direcionado culminou no diagnóstico presuntivo de pericardite tuberculosa (AU)

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.

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.