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.

[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.

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.

[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.

Pericarditis tuberculosa: informe de caso / Pericardial tuberculosis: case report

Introducción. La pericarditis tuberculosa es una manifestación infrecuente de tuberculosis en nuestro país. Se asocia con una morbilidad y mortalidad significativa y frecuentemente está asociada como causa de pericarditis constrictiva. Resulta de la extensión al pericardio de lesiones tuberculosas de pulmón, pleura, o adenitis mediastinales. Los medios diagnósticos más importantes son la radiografía de tórax, el electrocardiograma y el ecocardiograma, confirmándose el diagnostico por aspiración del liquido pericárdico o la realización debiopsia. Caso clínico. Se presenta caso de un paciente masculino de 54 años, ex –fumador, sin antecedentes patológicos importantes, quien se presentó con disnea y tos seca y datos de insuficiencia cardíaca congestiva progresivas de 2 meses de evolución. Desarrolló derrame pericárdico, del cual se drenó 2000cc de líquido hemorrágico. Posteriormente desarrolló derrame pleural derecho. La biopsia mostró pericarditis fibrinosa crónica granulomatosa. Discusión. El diagnostico oportuno y el tratamiento con antifímicos y esteroides mejoraron el cuadro clínico y el pronóstico de vida, como está escrito en la literatura...

Pericarditis tuberculosa: informe de caso / Pericardial tuberculosis: case report

Introducción. La pericarditis tuberculosa es una manifestación infrecuente de tuberculosis en nuestro país. Se asocia con una morbilidad y mortalidad significativa y frecuentemente está asociada como causa de pericarditis constrictiva. Resulta de la extensión al pericardio de lesiones tuberculosas de pulmón, pleura, o adenitis mediastinales. Los medios diagnósticos más importantes son la radiografía de tórax, el electrocardiograma y el ecocardiograma, confirmándose el diagnostico por aspiración del liquido pericárdico o la realización de biopsia. Caso clínico. Se presenta caso de un paciente masculino de 54 años, ex –fumador, sin antecedentes patológicos importantes, quien se presentó con disnea y tos seca y datos de insuficiencia cardíaca congestiva progresivas de 2 meses de evolución. Desarrolló derrame pericárdico, del cual se drenó 2000cc de líquido hemorrágico. Posteriormente desarrolló derrame pleural derecho. La biopsia mostró pericarditis fibrinosa crónica granulomatosa. Discusión. El diagnostico oportuno y el tratamiento con antifímicos y esteroides mejoraron el cuadro clínico y el pronóstico de vida, como está escrito en la literatura...(AU)

[Pericarditis due to multidrug resistant Mycobacterium tuberculosis in an HIV infected patient: case report and review of literature]. / Pericarditis por Mycobacterium tuberculosis multiresistente en un paciente con infección por VIH: Reporte de un caso clínico y revisión de la literatura.

Multidrug resistant Mycobacterium tuberculosis infection represents a new clinical challenge and it burdens threat. The association with HIV/AIDS makes very hard to treat these two co-infections. We present a patient of 30 years old whose HIV infection was diagnosed 4 years before, and acquired M. tuberculosis pericarditis without response to initial treatment because of a multidrug resistant TB strain. We describe the clinical management, outcome and final recovery of the patient. The epidemiology, diagnosis and treatment of TB pericarditis in HIV positive patients are reviewed.

Pericarditis por Mycobacterium tuberculosis multiresistente en un paciente con infección por VIH: Reporte de un caso clínico y revisión de la literatura / Pericarditis due to multidrug resistant Mycobacterium tuberculosis in an HIV infected patient: Case report and review of literature

Multidrug resistant Mycobacterium tuberculosis infection represents a new clinical challenge and it burdens threat. The association with HIV/AIDS makes very hard to treat these two co-infections. We present a patient of 30 years oíd whose HIV infection was diagnosed 4 years before, and acquired M. tuberculosis pericarditis without response to initial treatment because of a multidrug resistant TB strain. We describe the clinical management, outcome and final recovery of the patient. The epidemiology, diagnosis and treatment of TB pericarditis in HIV positive patients are reviewed.

La infección por Mycobacterium tuberculosis multi-resistente representa una nueva y grave amenaza. La asociación con infección por VIH/SIDA vuelve muy complejo el tratamiento exitoso de ambas infecciones. Presentamos el caso de un paciente de 30 años de edad, con cuatro años de diagnóstico de infección por VIH, que desarrolló una pericarditis por M tuberculosis sin una respuesta favorable inicial al tratamiento debido a que se trataba de una cepa multi-resistente. Se describe el manejo médico, evolución y recuperación final del paciente. Se revisa la epidemiología, diagnóstico y tratamiento de la pericarditis TBC en pacientes con infección por VIH.

[Tuberculous pericarditis. Ten years experience]. / Pericarditis tuberculosa. Experiencia de 10 años.

We review the clinical files of patients who entered the Regional General Hospital No. 20 IMSS in the City of Tijuana Mexico between May 1994 and May 2004 with diagnosis of primary acute pericardial disease. Patients diagnosed as having active tuberculous pericardial effusion were eligible for the study. Twenty-one were included in the study (14 men and 7 women). The aged ranged from 16 to 48 years (mean 36 years). The diagnosis was made by the following studies: identification of tubercle bacilli in the pericardial fluid or tissue (n = 4), identification of caseating granulomas in the pericardium or elsewhere (n = 2), positive culture for Mycobacterium tuberculosis in pericardial fluid (n = 8), in pleural fluid (n = 1), sputum culture (n = 3), gastric aspirate samples (n = 1), lymph node biopsy (n = 1), and pericardial effusion without obvious cause, responding to antituberculous therapy (n = 5). The clinical, laboratory, electrocardiography, radiographic, and echocardiography features were analyzed. We review in each patient follow-up, pericardial fluid cytology, and pericardial biopsy, if available. All patients had pericardial effusion; nine (42.8%) patients had cardiac tamponade. Pericardiocentesis was performed in 16 patients, "therapeutic" pericardiocentesis was performed in 43.7%, and "diagnostic" pericardiocentesis was performed in 56.2% all cases. Constrictive pericarditis developed in two patients, all required partial pericardiectomy. All patients received triple antituberculous chemotherapy. No patient died.

The usefulness of adenosine deaminase in the diagnosis of tuberculous pericarditis.

The objective of this study was to evaluate the adenosine deaminase (ADA) activity usefulness in the diagnosis of tuberculous pericarditis (TP), comparing its value with pericardial effusions (PE) caused by other pericardial diseases. A retrospective case-control study was conducted with nine cases of TP and 39 other than TP diseases (12 neoplastic, 11 septic and 16 unknown origin). Every patient included in this study had PE samples submitted to ADA activity measures and microbiological analysis, and then had pericardial tissue samples submitted to microbiological and histopathological examination. Considering the value of 40 U/L as the cut-off for the diagnosis of TP, the specificity and sensitivity were respectively of 72% and 89%. The specificity of ADA activity for the TP was best applied in the differential diagnosis from PE of unknown origin. The present study demonstrates the clinical value of the measurement of ADA activity in PE in the diagnosis of TP.

The usefulness of adenosine deaminase in the diagnosis of tuberculous pericarditis

The objective of this study was to evaluate the adenosine deaminase (ADA) activity usefulness in the diagnosis of tuberculous pericarditis (TP), comparing its value with pericardial effusions (PE) caused by other pericardial diseases. A retrospective case-control study was conducted with nine cases of TP and 39 other than TP diseases (12 neoplastic, 11 septic and 16 unknown origin). Every patient included in this study had PE samples submitted to ADA activity measures and microbiological analysis, and then had pericardial tissue samples submitted to microbiological and histopathological examination. Considering the value of 40 U/L as the cut-off for the diagnosis of TP, the specificity and sensitivity were respectively of 72 percent and 89 percent. The specificity of ADA activity for the TP was best applied in the differential diagnosis from PE of unknown origin. The present study demonstrates the clinical value of the measurement of ADA activity in PE in the diagnosis of TP.

O objetivo deste estudo foi avaliar a atividade da adenosina deaminase (ADA) como auxiliar no diagnóstico da tuberculose pericárdica (TP), comparando o seu valor no derrame pericárdico com outras doenças pericárdicas. Um estudo retrospectivo tipo caso-controle foi conduzido com nove casos de TP e 39 pacientes com outras doenças pericárdicas (12 neoplasias, 11 pericardites bacterianas e 16 pericardites de etiologia indeterminada). Cada paciente incluído no estudo teve sua amostra de tecido pericárdico encaminhada para estudo microbiológico e histopatológico. Considerando o valor de 40 U/L como corte para o diagnóstico de TP, a especificidade e sensibilidade foram respectivamente 72 e 89 por cento. A especificidade da atividade de ADA para a TP foi melhor aplicada no diagnóstico diferencial entre derrame pericárdico de origem indeterminada. O presente estudo demonstrou o valor clínico da mensuração da atividade de ADA no diagnóstico de TP.

Adenosine deaminase and tuberculous pericarditis--a systematic review with meta-analysis.

BACKGROUND: Adenosine deaminase (ADA) activity in pericardial fluid is a valuable aid in the diagnosis of tuberculous pericarditis (TP), but there is no systematic review performed to evaluate the benefits of ADA activity as an adjunctive test for TP diagnosis. The objective of this systematic review was to evaluate the utility of ADA activity as a diagnostic marker of TP on patients presenting with pericardial effusion. METHODS: MEDLINE, LILACS and Cochrane Library databases (1980-2005) searches to identify articles related to adenosine deaminase activity on TP diagnosis. Articles with patients with at least one TP diagnostic criteria were included. The controls were patients with other pericardial diseases with moderate or large pericardial effusion. To calculate the sensitivity, specificity, as well as positive and negative likelihood ratios we extracted the total number of confirmed TP cases over all patients with pericardial effusion as well as the number of cases with ADA activity values of 40 U/L and over. RESULTS: Thirty one studies met our initial inclusion criteria and five articles were selected. The heterogeneity limited the specificity analysis (p=0.004). The method yielded a sensitivity and specificity of 88% and 83%, respectively. The SROC curve presented an area with a tendency towards 1 (value of 0.9539) and corroborates the diagnostic value of ADA activity. CONCLUSIONS: The present study confirms the clinical value of ADA activity as adjunctive diagnostic marker of TP among other causes of pericardial effusion.