The immunopathogenesis of tuberculous pericarditis.

Tuberculous pericarditis is a severe form of extrapulmonary tuberculosis and is the commonest cause of pericardial effusion in high incidence settings. Mortality ranges between 8 and 34%, and it is the leading cause of pericardial constriction in Africa and Asia. Current understanding of the disease is based on models derived from studies performed in the 1940-50s. This review summarises recent advances in the histology, microbiology and immunology of tuberculous pericarditis, with special focus on the effect of Human Immunodeficiency Virus (HIV) and the determinants of constriction.

Epidemiology of pericardial diseases in Africa: a systematic scoping review.

OBJECTIVES: This scoping review sought to summarise available data on the prevalence, aetiology, diagnosis, treatment and outcome of pericardial disease in Africa. METHODS: We searched PubMed, Scopus and African Journals Online from 1 January 1967 to 30 July 2017 to identify all studies published on the prevalence, aetiologies, diagnosis, treatment and outcomes of pericardial diseases in adults residing in Africa. RESULTS: 36 studies were included. The prevalence of pericardial diseases varies widely according to the population of interest: about 1.1% among people with cardiac complaints, between 3.3% and 6.8% among two large cohorts of patients with heart failure and up to 46.5% in an HIV-infected population with cardiac symptoms. Tuberculosis is the most frequent cause of pericardial diseases in both HIV-uninfected and HIV-infected populations. Patients with tuberculous pericarditis present mostly with effusive pericarditis (79.5%), effusive constrictive pericarditis (15.1%) and myopericarditis (13%); a large proportion of them (up to 20%) present in cardiac tamponade. The aetiological diagnosis of pericardial diseases is challenging in African resource-limited settings, especially for tuberculous pericarditis for which the diagnosis is not definite in many cases. The outcome of these diseases remains poor, with mortality rates between 18% and 25% despite seemingly appropriate treatment approaches. Mortality is highest among patients with tuberculous pericarditis especially those coinfected with HIV. CONCLUSION: Pericardial diseases are a significant cause of morbidity and mortality in Africa, especially in HIV-infected individuals. Tuberculosis is the most frequent cause of pericardial diseases, and it is associated with poor outcomes.

Exudative-constrictive tuberculous pericarditis in combination with arthritis in cardiologist practice: thoracoscopic biopsy as a diagnosis and treatment method.

AIM: The goal is to present the possibilities of diagnosis verification, the features of the clinical picture of tuberculous pericarditis in the therapeutic clinic and the results of its treatment. MATERIALS AND METHODS: The paper presents clinical observation and a general analysis of 10 cases of tuberculous pericarditis in patients aged 31-79 (mean age 58.0 ± 15.1 years), 6 women and 4 men. Diagnostic puncture pericardium was performed on two patients, pleural puncture - on three Thoracoscopic biopsy of hilar lymph nodes and lung (n=1), pleura (n=1), supraclavicular lymph node biopsy (n=1). Dyskin test was carried out, as well as sputum examination, multispiral computed tomography, oncological search. RESULTS: A 31-year-old patient with a massive effusion in the pericardial cavity, pleural lesion, arthritis of the left knee joint, whose results of the pericardial effusion and sputum were not diagnosed, tuberculosis was detected only with thoracoscopic biopsy of the lung and intrathoracic lymph nodes; the treatment via prednisolone and subtotal pericardectomy was performed. Among 10 patients with MSCT of the lung, changes were noted in general, but in only one case they were highly specific. Diaskin test is positive in 70%. In the study of punctata, bronchoalveolar flushing, Koch bacteria were not detected; at sputum in microscopy and biological sample BC was detected in two patients. The lymphocytic character of effusion in the pericardium / pleura is noted in 4 out of 5 cases. At a biopsy of lymphonoduses and a lung at 2 patients the picture of a granulomatous inflammation with a caseous necrosis. Pericarditis was predominantly large (from 2 cm and more) effusion, signs of constriction were noted in 50% of patients. CONCLUSION: Tuberculosis is one of the frequent causes of pericarditis in the Moscow therapeutic clinic. The most lymphocytic effusion with fibrin and the development of constriction. The negative results of all laboratory tests for tuberculosis do not exclude a diagnosis, It is necessary to use invasive morphological diagnostics, including thoracoscopic biopsy.

Tuberculous and Infectious Pericarditis.

Viral pericarditis is the most common cause of acute pericarditis and it is typically responsive to aspirin or nonsteroidal anti-inflammatory drugs. Tuberculous pericarditis is common in immunocompromised patients or in immunocompetent patients in endemic areas. The diagnosis of tuberculous pericarditis usually requires a multidisciplinary approach, and presumptive treatment should be started for people with suspected infections living in endemic areas. Antituberculous treatment along with corticosteroid therapy can reduce complications from constrictive pericarditis. Purulent pericarditis is fatal if untreated. Bacterial and fungal cultures from pericardial fluid and blood are essential to determine the best treatment.

Predictive factors for unfavorable outcomes of tuberculous pericarditis in human immunodeficiency virus-uninfected patients in an intermediate tuberculosis burden country.

BACKGROUND: In areas where Mycobacterium tuberculosis is endemic, tuberculosis is known to be the most common cause of pericarditis. However, the difficulty in diagnosis may lead to late complications such as constrictive pericarditis and increased mortality. Therefore, identification of patients at a high risk for poor prognosis, and prompt initiation of treatment are important in the outcome of TB pericarditis. The aim of this study is to identify the predictive factors for unfavorable outcomes of TB pericarditis in HIV-uninfected persons in an intermediate tuberculosis burden country. METHODS: A retrospective review of 87 cases of TB pericarditis diagnosed at a tertiary referral hospital in South Korea was performed. Clinical characteristics, treatment outcomes, complications during treatment, duration of treatment, and medication history were reviewed. Unfavorable outcome was defined as constrictive pericarditis identified on echocardiography performed 3 to 6 months after initial diagnosis of TB pericarditis, cardiac tamponade requiring emergency pericardiocentesis, or death. Predictive factors for unfavorable outcomes were identified. RESULTS: Of the 87 patients, 44 (50.6%) had unfavorable outcomes; cardiac tamponade (n = 36), constrictive pericarditis (n = 18), and mortality (n = 4). 14 patients experienced both cardiac tamponade and constrictive pericarditis. During a 1 year out-patient clinic follow up, 4 patients required repeat pericardiocentesis and pericardiectomy was performed in 0 patients. In the multivariate analysis, patients with large amounts of pericardial effusion (P = .003), those with hypoalbuminemia (P = .011), and those without cardiovascular disease (P = .011) were found to have a higher risk of unfavorable outcomes. CONCLUSION: HIV-uninfected patients with TB pericarditis are at a higher risk for unfavorable outcomes when presenting with low serum albumin, with large pericardial effusions, and without cardiovascular disease.

Guía ESC 2015 sobre el diagnóstico y tratamiento de las enfermedades del pericardio / 2015 ESC guidelines for the diagnosis and management of pericardial diseases

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Host-directed therapies for tuberculous pericarditis.

TB Pericarditis is associated with significant inflammatory and immune responses which can paradoxically cause injury to the pericardium and myocardium. Management with anti-TB therapy alone does not prevent complications or reduce mortality. Thus the prevailing view is that adjunct host-directed therapies such as use of glucocorticoid treatment could attenuate destructive inflammatory responses and improve morbidity and mortality rates. A recent trial showed no advantage of using adjunct corticosteroid treatment on the combined endpoint of death, cardiac tamponade or constriction. The current lack of effective medical treatment for reducing the significant morbidity and mortality associated with TB pericarditis, highlights the urgent need for newer approaches to treating the disease. Newer treatment options for pericarditis using adjunct host-directed therapies, including autologous bone-marrow-derived Mesenchymal Stromal Cells (MSCs) therapy, now require evaluation in randomized placebo-controlled controlled trials.

Uncommon cause of left ventricular pseudoaneurysm: case report and review of literature.

We report a case of an 18-year-old man without tuberculosis history who presented with chest distress, dyspnea, and fever. Chest computed tomography scan and echocardiography showed left ventricular posterior wall pseudoaneurysm and perforation. Unfortunately, the patient died shortly after surgery. On the basis of surgical pathology, we made a final diagnosis of tuberculous pericarditis complicated with left ventricular pseudoaneurysm. This has not been reported before in the published literature.

Tuberculous pericarditis with and without HIV.

The human immunodeficiency virus (HIV) has altered the epidemiology, clinical manifestations, treatment considerations and natural history of tuberculous (TB) pericarditis with significant implications for clinicians. The caseload of TB pericarditis has risen sharply in TB endemic areas of the world where co-infection with HIV is common. Furthermore, TB is the cause in greater than 85 % of cases of pericardial effusion in HIV-infected cohorts. In the absence of HIV, the morbidity of TB pericarditis is primarily related to the ferocity of the immune response to TB antigens within the pericardium. In patients with HIV, because TB pericarditis more often occurs as part of a disseminated process, the infection itself has a greater impact on the morbidity and mortality. HIV-associated TB pericarditis is a more aggressive disease with a greater degree of myocardial involvement. Patients have larger pericardial effusions with more frequent hemodynamic compromise and more significant ST segment changes in the electrocardiogram. HIV alters the natural history and outcomes of TB pericarditis. Immunocompromised participants appear less likely to develop constrictive pericarditis and have a significantly higher mortality compared with their immunocompetent counterparts. Finally co-infection with HIV has resulted in a number of areas of uncertainty. The mechanisms of myocardial dysfunction are unclear, new methods of improving the yield of TB culture and establishing a rapid bacterial diagnosis remain a major challenge, the optimal duration of anti-TB therapy has yet to be established, and the role of corticosteroids has yet to be resolved.

[Extrapulmonary tuberculosis]. / La tuberculose extrapulmonaire.

Extrapulmonary tuberculosis represents an increasing proportion of all cases of tuberculosis reaching 20 to 40% according to published reports. Extrapulmonary TB is found in a higher proportion of women, black people and immunosuppressed individuals. A significant proportion of cases have a normal chest X-Ray at the time of diagnosis. The most frequent clinical presentations are lymphadenitis, pleuritis and osteoarticular TB. Peritoneal, urogenital or meningeal tuberculosis are less frequent, and their diagnosis is often difficult due to the often wide differential diagnosis and the low sensitivity of diagnostic tests including cultures and genetic amplification tests. The key clinical elements are reported and for each form the diagnostic yield of available tests. International therapeutic recommendations and practical issues are reviewed according to clinical presentation.

[Diagnosis and effective surgical treatment of constrictive pericarditis].

Constrictive pericarditis is a rare and severe disease. Timely and correct differential diagnosis of this pathology facilitates choice of necessary tactics of treatment and thus improve prognosis and quality of life. In this paper we present clinical case report of a patient with constrictive pericarditis. The disease was diagnosed on the basis of clinical picture, data of X-ray and echocardiographic investigation, and confirmed by multispiral computed tomography (MSCT). The patient was subjected to pericardioectomy with positive clinical effect and results of repeated echocardiography and MSCT.

[Tuberculous pericarditis. A case reported and a brief review]. / Pericarditis tuberculosa. Informe de un caso y revisión de la literatura.

Pericarditis in patients with tuberculosis is estimated from one to eight percent. The tuberculosis is considered endemic in developing countries and tuberculous pericarditis is found frequently in patients with the Acquired Immunodeficiency Syndrome (AIDS). This entity is characterized by mediastinal or hilar lymph nodes, sternum or spine with retrograde tracheobronchial extension. Spread may also take place by the hematogenous route. The beginning can be suddenly, like an unknown pericarditis, with cough, dyspnea, chest pain, ankle edema, fever, tachycardia, and night sweats. Clinical examination shows pericardial friction rub, liver congestion, ascites, edema and low intensity cardiac noise. Chest radiograph shows cardiomegaly. The two-dimensional echocardiography verifies pericardial effusion. The PPD skin test can be negative in 30% by the presence of anergy. Definitive diagnosis is the demonstration of pericardium inflammatory granulomas and the presence of acid-alcohol resistant bacilli in the pericardial biopsy. We conclude that the tuberculous pericarditis diagnosis should be established by clinical suspicion, two-dimensional echocardiography and pericardiocentesis and later pericardiectomy must be practiced as soon as possible before receiving pharmacological treatment with triple drug therapy and steroids.

[Diagnosis of tuberculous pericarditis in patients with HIV-infection].

AIM: To study specific features of the incidence, course and diagnosis of tuberculosis pericarditis (TP) in patients with HIV-infection. MATERIAL AND METHODS: We analysed results of diagnosis of 304 primary patients with organ tuberculosis in combination with HIV infection treated in Moscow tuberculosis hospital N 7 in 2006-2010. CD4 lymphocyte count median in tuberculosis onset was 140 in 1 mcl, 63.2% patients had a baseline level of CD4 lymphocytes under 200 in 1 mcl. RESULTS: TP incidence in primary patients with tuberculosis and HIV-infection was 6.3% while in patients with tuberculosis of multiple locations--13.7%. Cardiac tamponade symptoms were registered only in one case. Pericardial effusion was classified as moderate and large in 68.4% patients. Patients with large effusion (more than 20 mm in isolation of pericardial leaves) have undergone diagnostic pericardiocentesis and, in some cases, microdrainage. Sensitivity of exudate test for M. tuberculosis DNA with use of polymerase chain reaction was 100%. CONCLUSION: Active surgical policy in massive effusion tuberculosis pericarditis in line with adequate antituberculosis and antiretrovirus therapy in HIV-infected patients results in rapid resorption of the effusion.

Tuberculosis pericarditis with cardiac tamponade: management in the resource-limited setting.

We report a case of human immunodeficiency virus-associated pericardial tuberculosis complicated by cardiac tamponade. Emergency management and subsequent therapeutic interventions are described and then discussed with particular focus on resource-limited settings. The paucity of evidence to support clinical decisions is emphasized and the need for well designed diagnostic and therapeutic studies is highlighted.