Diagnosis and Management of Tuberculous Pericarditis: What Is New?

PURPOSE OF REVIEW: This review provides an update on the immunopathogenesis of tuberculous pericarditis (TBP), investigations to confirm tuberculous etiology, the limitations of anti-tuberculous therapy (ATT), and recent efficacy trials. RECENT FINDINGS: A profibrotic immune response characterizes TBP, with low levels of AcSDKP, high levels of γ-interferon and IL-10 in the pericardium, and high levels of TGF-ß and IL-10 in the blood. These findings may have implications for future therapeutic targets. Despite advances in nucleic acid amplification approaches, these tests remain disappointing for TBP. Trials of corticosteroids and colchicine have had mixed results, with no impact on mortality, evidence of a reduction in rates of constrictive pericarditis and potential harm in those with advanced HIV. Small studies suggest that ATT penetrates the pericardium poorly. Given that there is a close association between high bacillary burden and mortality, a rethink about the optimal drug doses and duration may be required. The high mortality and morbidity from TBP despite use of anti-tuberculous drugs call for researches targeting host-directed immunological determinants of treatment outcome. There is also a need for the identification of steps in clinical management where interventions are needed to improve outcomes.

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.

Clostridium difficile infection associated with antituberculous agents in a patient with tuberculous pericarditis.

Clostridium difficile can cause pseudomembranous colitis (PMC). Antimicrobial agent exposure is a risk factor for Clostridium difficile-associated disease, whereas the use of antituberculous (anti-TB) agents is not. We herein report a case of PMC-associated with antituberculous therapy. A 63-year-old woman with tuberculous pericarditis treated with anti-TB agents was admitted for abdominal pain and diarrhea. On colonoscopy, mucoid exudate and yellowish plaque lesions were observed. The anti-TB agents were discontinued, and the patient was treated with metronidazole and clostridium butyricum. Her symptoms were relieved and did not recur when the anti-TB agents were restarted. In this report, we review the literature and discuss the pathogenesis, clinical manifestations, diagnosis and treatment of this case.

Tuberculosis in hematopoietic stem cell transplant patients: case report and review of the literature.

The literature describing tuberculosis (TB) in hematopoietic stem cell transplant (HSCT) recipients is scant, even in countries where TB is common. We describe a case of pulmonary TB in a patient who underwent HSCT and review the English language literature on this subject. An extensive PubMed and Ovid search was undertaken for the period January 1980 to March 2009; the search terms used were 'Mycobacterium tuberculosis' or 'tuberculosis', in combination with 'hematopoietic stem cell transplantation' or 'bone marrow transplantation'. The patient in the present case report underwent allogeneic transplantation and developed TB 8 days after his HSCT. The patient had received vaccination against TB in childhood. During the year prior to the HSCT he had had contact with a relative who had pulmonary TB. On day 3 of anti-TB treatment he developed pericarditis. The patient received anti-TB treatment for 6 months without major problems. From the literature review, we found 34 related studies, 25 on the clinical manifestations of TB. Most of the reports were from Asia (48%), and the incidence of TB varied from 0.0014% in the USA to 16% in Pakistan. TB occurred at between +21 and +1410 days post-HSCT (257.2 days the median), and the lung was the organ most frequently involved. Mortality varied from 0% to 50% and was higher in allogeneic HSCT. There is no consensus regarding screening with the tuberculin skin test or primary prophylaxis for latent TB, and further research into this is necessary in developing countries with a high prevalence of TB.

Aetiological diagnosis in acute and recurrent pericarditis: when and how.

The cause of acute and recurrent pericarditis is often a major concern for the clinicians in clinical practice. Several possible causes of pericarditis can be listed, as the pericardium may be involved in a large number of systemic disorders or may be diseased, as an isolated process. The reported diagnostic yield of extensive laboratory evaluation and pericardiocentesis is low in the absence of cardiac tamponade or suspected neoplastic, tuberculous, and purulent pericarditis. Patients with pericarditis can be safely managed on an outpatient basis without a thorough diagnostic evaluation unless a specific cause is suspected or the patient has high-risk features, or both. A targeted aetiological search should be directed to the most common cause on the basis of the clinical background, epidemiological issues or specific presentations. In developed countries the clinicians should rule out neoplastic, tuberculous, and purulent pericarditis, as well as pericarditis related to a systemic disease.

Tuberculous pericarditis.

BACKGROUND: The incidence of tuberculous pericarditis is increasing in Africa as a result of the human immunodeficiency virus (HIV) epidemic. The primary objective of this article was to review and summarize the literature on the pathogenesis, diagnosis, and management of tuberculous pericarditis. METHODS AND RESULTS: We searched MEDLINE (January 1966 to May 2005) and the Cochrane Library (Issue 1, 2005) for information on relevant references. A "definite" diagnosis of tuberculous pericarditis is based on the demonstration of tubercle bacilli in pericardial fluid or on a histological section of the pericardium; "probable" tuberculous pericarditis is based on the proof of tuberculosis elsewhere in a patient with otherwise unexplained pericarditis, a lymphocytic pericardial exudate with elevated adenosine deaminase levels, and/or appropriate response to a trial of antituberculosis chemotherapy. Treatment consists of the standard 4-drug antituberculosis regimen for 6 months. It is uncertain whether adjunctive corticosteroids are effective in reducing mortality or progression to constriction. Surgical resection of the pericardium remains the appropriate treatment for constrictive pericarditis. The timing of surgical intervention is controversial, but many experts recommend a trial of medical therapy for noncalcific pericardial constriction, and pericardiectomy in nonresponders after 4 to 8 weeks of antituberculosis chemotherapy. CONCLUSIONS: Research is needed to improve the diagnosis, assess the effectiveness of adjunctive steroids, and determine the impact of HIV infection on the outcome of tuberculous pericarditis.

Tuberculous pericardial effusion--mediastinal lymph glands: the cause and clue to the etiology.

BACKGROUND: Tuberculous pericardial effusion is most often due to the spread of tuberculosis from the mediastinal lymph glands; however, no attempt has yet been made to study these glands. We studied the mediastinal glands in proven tuberculous pericardial effusion patients and hypothesized that the findings may be of use in the etiological diagnosis of pericardial effusion. METHODS AND RESULTS: We studied 45 patients with large pericardial effusion or tamponade. All underwent chest computed tomographic studies that were reviewed by radiologists blinded to the diagnosis. Of these 45 patients, 27 had tuberculosis and 18 had viral or idiopathic effusion. Pericardial biopsy was done in 25/27 and tuberculin skin test in 22/27 patients with tuberculosis, and all received specific treatment. In patients with tuberculosis the skin test measured 17+/-3.3 mm. All 27 had mediastinal lymph glands > or = 10 mm in size. The mean size of the mediastinal glands was 19.5+/-8.6 mm and the mean number was 2.5+/-1.2. The aortopulmonary glands were the most frequently enlarged (63%), and hilar the least often (14.8%). The glands showed a hypodense center in 52% of the patients. On follow-up of 15.8+/-10.4 months, glands were not seen in 80.9%, and were smaller in size in 19%; none had a hypodense center. Marked lymphadenopathy was not seen in any patient with viral/idiopathic pericardial effusion. Two had glands < or = 5 mm in size. CONCLUSIONS: Only patients with tuberculosis had substantial mediastinal lymph gland enlargement and not those with viral or idiopathic pericardial effusion. Such glands disappeared or regressed on treatment. In the appropriate clinical context, marked nonhilar mediastinal lymphadenopathy on chest computed tomographic studies along with a strongly positive tuberculin skin test could be of value in the noninvasive diagnosis of pericardial effusion due to tuberculosis.

Myocarditis and pericarditis with tamponade associated with disseminated tuberculosis.

Tuberculous involvement of the myocardium is relatively rare. Tuberculous pericarditis with tamponade and myocarditis in a young woman with no evidence of immunosuppression and disseminated tuberculosis is described. Three distinct forms of myocardial involvement are recognized: nodular tubercles (tuberculomas) of the myocardium; miliary tubercles of the myocardium; and an uncommon diffuse infiltrative type. The myocardium is involved by a hematogenous route, by lymphatic spread or contiguously from the pericardium. The diagnosis can be made by endomyocardial biopsy if clinical suspicion is strong and echocardiographic findings are suggestive. Antituberculosis drugs may be curative. With an increasing prevalence of tuberculosis, the possibility of potentially lethal myocardial tuberculosis is important to consider.

[A case of MPO ANCA associated glomerulonephritis with interstitial pneumonitis complicated with lung tuberculosis and pericarditis].

The main target organs of myeloperoxidase (MPO) antineutrophil cytoplasmic antibodies (ANCA)-related disease are the kidney and lung. This report describes a 71-year-old man with rapidly progressive glomerulonephritis (RPGN) and interstitial pneumonitis associated with MPO ANCA. The patient was admitted to our hospital because of bloody sputum, low grade fever and appetite loss on October, 1998. He was diagnosed as having interstitial pneumonitis from the findings of chest X-ray and CT examinations. Moderate proteinuria and hematuria, renal dysfunction(serum creatinine: 5.6 mg/dl, BUN: 58.0 mg/dl) and positivity for MPO ANCA were noted. He was negative for anti-glomerular antibody and PR3-ANCA. Renal biopsy was performed and revealed crescentic glomerulonephritis without deposition of immunoglobulins. Therefore, the diagnosis of pauci immune type RPGN was made. Pulse therapy with methylprednisolone(1.0 g/day x 3 days) following oral administration of prednisolone (60 mg/day) found marked improvement of renal function maintenance and interstitial pneumonitis, respectively. However, he died because of lung tuberculosis and acute tuberculous pericarditis during treatment with prednisolone. In this case, MPO ANCA might have been directly associated with both RPGN and interstitial pneumonitis. Furthermore, chronic lung disease, such as interstitial pneumonitis, is important as a preceding disease of RPGN. MPO ANCA-related disease is more frequent in aged persons, therefore particular attention should be paid during their treatment with an immunosuppressant.

Valor del líquido pericárdico con relación a la biopsia pericárdica en el diagnóstico de pericarditis efusiva tuberculosa / Value of I eliminate pericardico in relation to the pericárdica biopsy in the diagnosis of tuberculosa efusiva pericarditis

Objetivo: Determinar el valor del líquido pericárdico con relación a la biopsia pericárdica en la pericarditis efusiva tuberculosa y el grado de concordancia entre el diagnóstico por líquido pericárdico y el diagnóstico por biopsia pericárdica. Material y métodos: Se analizaron retrospectivamente las historias clínicas de 19 pacientes con diagnóstico pre-operatorio de pericarditis efusiva, entre los años 1994 y 1999, que acudieron al servicio de cirugía de Tórax y Cardiovascular del Hospital Nacional Cayetano Heredia. Se consideró diagnóstico confirmado de pericarditis tuberculosa a los pacientes que cumplían los siguientes criterios por estudio de líquido pericárdico (cultivo positivo para Bacilo de Koch o examen directo de Bacilo de Koch positivo o valor de ADA mayor a 50 UI/L) y/o los siguientes criterios por estudio de biopsia pericárdica (Cultivo positivo para Bacilo de Koch y granuloma con necrosis caseosa o presencia de células gigantes multinucleadas tipo Langhans o presencia de BAAR en la muestra). Resultados: De los 19 pacientes con diagnóstico de pericarditis efusiva. 12 pacientes tuvieron el diangóstico confirmado de pericarditis tuberculosa, según criterios establecidos. De estos 12 pacientes, solo 6 pacientes cumplieron con ambos criterios, 5 pacientes solo con los criterios por estudio de líquido pericárdico, y un paciente, solo con los criterios por estudio de biopsia pericárdica. Se obtuvo una sensibilidad y especificidad para el estudio del líquido pericárdico de 85.7 por ciento y 58.3 por ciento respectivamente, con un valor predictivo positivo y valor predictivo negativo de 54.5 por ciento y 87.5 por ciento respectivamente. Además se encontró un grado de concordancia entre ambos métodos diagnósticos de 0.394. Conclusión: El estudio de líquido pericárdico en la pericarditis efusiva tuberculosa, tiene mayor utilidad para descartar dicha etiología que para confirmarla, por lo que es mandatoria la necesidad de obtener una biopsia de tejido pericárdico para confirmar la etiología tuberculosa.

Tuberculosis and pericarditis in children.

With the rapid spread of tuberculosis (TB) in Zimbabwe the disease is becoming a major paediatric health problem. Children are at high risk of TB, are prone to disseminated disease and the diagnosis of paediatric TB may be difficult, since complaints often are unspecific and contacts may not been known. Data from 265 children, aged between 2 weeks and 12 years, being treated for TB in Gweru Hospital in 1995, are analysed. In 72% pericardial effusion was found as a sign of early dissemination. Cultures of gastric aspirates for Mycobacterium tuberculosis were positive in 31%. In optimal circumstances the yield for isolates of M. tuberculosis is less than 50%, and these results under limited conditions are acceptable, and may reflect the true incidence. Given the epidemiology of TB in Zimbabwe, pericardial effusions should be considered indicative of TB until proven otherwise.

[The etiological structure of pericarditis]. / K voprosu ob étiologicheskoi strukture perikardita.

Data are submitted from the published literature and the authors' observations on causation of pericarditis and transformation of its patterns over the last 24 years. The paper is based on the analysis of 325 patients having been operated on for constrictive pericarditis during the period 1974-1998. Over the last 12 years there has been an increase in the incidence of pericarditis of nonspecific etiology whereas that of pericarditis of rheumatic and tuberculous genesis has gotten substantially decreased.

Tuberculous pericarditis and AIDS: case reports and review.

Pericarditis is one of the most common cardiac complications in the course of HIV disease. Opportunistic infections and neoplastic processes represent the most common etiology of pericardial disease. Pericardial tuberculosis is an uncommon condition, especially in developed countries. Two cases of tuberculous pericarditis in adult patients with AIDS occurred over a 12-month period at our clinic, which prompted a literature review of the published cases of tuberculous pericarditis in AIDS. Of note is that in the first patient pericardial effusion represented the AIDS-defining illness and was an expression of a disseminated tuberculous disease. The second patient developed a fatal pericarditis due to a multiple-drug resistant Mycobacterium tuberculosis infection.

[HIV infection and pericardial disease invasion in Africa]. / Irruption de l'infection par le VIH et des pèricardites en Afrique.

The number of cases with pericardial disease has been increasing in Africa and particularly in Zäire, after AIDS was defined. To investigate a possible link between HIV infection and risen incidence of pericardial effusions, 64 patients randomly selected (32 HIV carriers and 32 HIV-seronegative as controls), with suspected pericardial disease were studied in a longitudinal trial from January 1991 to December 1994. Central and accessory cells of immune system were measured in conjunction with blood screening, electrocardiogram (ECG), chest X-ray and cardiac ultrasound. Haematological examination included also microscopical examination of blood films after May-Grünwald-Giemsa staining. There were significant decreases of hemoglobin, CD4 cells, and basophils in HIV-seropositive patients. Pericardial disease was estimated 8.8% of in-hospital prevalence, in which 70% of cases were related to HIV infection. The HIV related pericardial disease had an incidence of 1.8% per year. Etiology of pericardial disease depends on evolution and immunodepression level; 90.5% of pericardial effusions related to HIV are caused by tuberculosis as shown at the second pericardiocenthesis.