Tjiang W, See KS Kris
Abstract
Background : Extrapulmonary tuberculosis occurs in 20% of patients with tuberculosis. Tuberculous pericarditis is shown in 1-8% of these patients. Tubercular pericarditis can develop at any age but commonly occurs in middle age. Prompt treatment can be life saving. Effective treatment requires a rapid and accurate diagnosis but is often difficult. We present such a case of tubercular pericarditis with signs of constrictive pericarditis and subsequently went for thoracotomy, pericardial window, WSD, sternotomy and pericardiectomy.
Case Presentation : We report a case of a 24-year-old male with shortness of breath, associated with cough, orthopnea, paroxysmal nocturnal dyspnea, night sweat, loss of weight, and bilateral leg swelling with history of TB contact. He had tachycardia, raised JVP, cardiomegaly, reduced breath sound over left hemithorax, and leg oedema. Chest X-ray showed cardiomegaly with left pleural effusion and ECG revealed low voltage, with inverted T. Ecocardiography confirmed pericardial effusion with signs of constriction. Anti tuberculosis treatment (FDC) was started earlier based on high index suspicion of tuberculosis and subsequently patient went for thoracotomy, pericardial biopsy, pericardial window and WSD. Pericardial and pleural fluid showed lymphocyte predominant and pericardial biopsy revealed granulomatous inflammation. And then sternotomy with pericardiectomy were carried out which showed stiff pericardium with 1 cm thickness of fibrosis. Patient was discharged after 2 months of admission and responding well to the anti TB treatment, with no recurrence of symptoms or any signs of deterioration when last followed up.
Conclusions : Clinicians should have a high index of suspicion of TB pericarditis when encountering a patient with pericardial effusion, especially if co-existent pleural effusion is noticed. The goal of therapy of tubercular pericarditis is not only relief of the symptoms, but also to prevent progression from the effusive to the constrictive stage. If constrictive pericarditis presents, pericardiectomy is the treatment of choice.
Keywords : Tubercular pericarditis, Pericardial window, Granulomatous inflammation Pericardiectomy, Fixed drug combination.
Background
Extrapulmonary tuberculosis occurs in 20% of patients with tuberculosis. Tuberculous pericarditis is shown in 1-8% of these patients. Tubercular pericarditis can develop at any age but commonly occurs in middle age. Prompt treatment can be life saving. Effective treatment requires a rapid and accurate diagnosis but is often difficult.
Patient presented with respiratory and heart failure signs and symptoms, with chest x-ray showed cardiomegaly and left pleural effusion, low voltage with inverted T in ecg and confirmation of pericardial effusion with signs of constriction from echocardiography. This case report highlights that a high degree of clinical suspicion of TB pericarditis, especially when encountering a patient with pericardial effusion with co-existent pleural effusion, followed by prompt diagnosis and treatment.
Case Presentation
A 24-year-old male presented to hospital with shortness of breath on exertion for 2 months duration, associated with cough and minimal whittish sputum, orthopnea, paroxysmal nocturnal dyspnea, night sweat, loss of weight 10 kg over last 6 months, bilateral leg swelling. His past medical history unremarkable. He denied diabetes, smoking, alcoholic drinking or taking any medication. He lived with his uncle who had pulmonary tuberculosis on treatment. Prior to admission, he was admitted for 2 weeks in district hospital without any improvement.
On examination, he was weak, undernourished, non icteric. Body weight 52 kg, height 170 cm. His blood pressure 110/70 mmHg, heart rate 120x/minute, respiratory rate 40x/minute, temperature 36.5 C. He had raised JVP, cardiomegaly, reduced breath sound with dullness in percussion over left hemithorax, crepitation over basal of bilateral lung, ascites and bilateral leg oedema.
Initial blood test revealed hemoglobin of 14.8 g/dl, leucocyte 7,800/µl with segment 94 %, lymphocyte 3.9%, platelet count of 250x103/µl. Renal function and liver enzyme was normal. Total protein 6.7 g/dl, albumin level 2,9 g/dl, blood sugar 105 mg/dl, sodium 135 mmol/L, potassium 3.5 mmol/L, ckmb 1.9 U/L. ECG revealed tachycardia HR 130x/minute , low voltage, with inverted T in anterior and inferior. Chest X-ray showed left pleural effusion, with sign of pulmonary oedema and cardiomegaly. Ecocardiography showed pericardial effusion with signs of constriction, reduced global systolic and segmental left ventricular function, EF 39%. Abdominal ultrasound only showed ascites. AFB x2 negative.
Patient was given furosemide and was started with adjuvant anti TB treatment with FDC / Fixed drug Combination (Four combined antituberculous therapy), and was consulted cardiothoracic surgeon for pericardiectomy and thoracotomy. Thoracotomy, pericardial biopsy, pericardial window and WSD (Water Sealed Drainage) through left hemithorax were carried out. Drainage out 800 cc serous pleural fluid, and was sent for culture and analysis. Patient was then admitted to ICU and started iv antibiotic. Pericardial fluid (serohaemorrhagic fluid) analysis showed cell count 11700, erythrocyte positive, segment 15%, lymphocyte 85%, protein 4.5 g%, glucose 0 mg. Pleural fluid analysis showed cell count 300, erythrocyte positive, segment 25%, lymphocyte 75%, protein 2.4 g%, glucose 91 mg. Pericardial and pleural fluid culture were negative. Pericardial biopsy revealed connective tissue with hyalinization and giant cells langhans, concluded as granulomatous inflammation suggestive of tuberculosis.
Repeated echocardiography at third week of admission showed constrictive signs at posterior, lateral, and apical, with EF 35 %. Blood investigations showed hemoglobin of 11.5 g/dl, leucocyte 16,100/µl with segment 79 %, lymphocyte 7.8%, platelet count of 433x103/µl. Renal function and liver enzyme was normal. Total protein 5.2 g/dl, albumin level 1,9 g/dl, blood sugar 105 mg/dl, sodium 135 mmol/L, potassium 3.6 mmol/L. HbsAg negative, anti HIV negative. Patient was then started methylprednisolon 1mg/kg body weight for 2 weeks and slowly tapered down, FDC was continued, and surgical procedure pericardiectomy was done by standard median sternotomy, and noted stiff pericardium with 1 cm thickness of fibrosis, drainage out serohaemorrhagic fluid 30-50 cc/12 hour through substernal WSD. On the following weeks, patient’s symptom was improved, no more dyspnea, reduced ascites and leg swelling, vital sign are stable, WSD was off. Repeated chest x-ray showed minimal pleural effusion. Patient was discharged after 2 months of admission and continuing his FDC with outpatient clinic follow up. The patient was responding well to the treatment, with no recurrence of symptoms or any signs of deterioration when last followed up.
Discussion
Extrapulmonary tuberculosis occurs in 20% of patients with tuberculosis. Tuberculous pericarditis is shown in 1-8% of these patients.5 Tubercular pericarditis can develop at any age but commonly occurs in middle age.9
The clinical presentation of tubercular pericarditis is variable and non-specific with symptoms including fever, night sweats, fatigue, and weight loss. Most common symptoms are cough, chest pain and dyspnea. In some cases, evidence of chronic cardiac compression mimicking heart failure can be present. Cardiac tamponade may present as a complication of pericardial effusion. Sometimes vague symptoms make the condition difficult to recognize. This effusion is mainly due to hypersensitivity to tubercular protein. The route of spread of the organisms to pericardium is usually from mediastinal or hilar lymph nodes or from lungs or rarely as a part of miliary tuberculosis.5 Chest radiograph which shows an enlarged cardiac shadow in more than 90% cases, demonstrates features of active pulmonary disease in 30% cases. The ECG is abnormal in virtually all cases of tubercular pericarditis.11 Low-voltage QRS and inverted T-waves were the characteristic findings of electrocardiogram in TB pericarditis in one previous report.4
In this case, ourpatient was middle age man presented with respiratory and heart failure signs and symptoms, with raised JVP, bilateral leg oedema, with a chest x-ray showed cardiomegaly with sign of pulmonary oedema and left pleural effusion, and the ecg showed low voltage with inverted T. The initial suspicion of pericardial effusion was confirmed with echocardiography, with a sign of constriction, and with co-existent pleural effusion, and history of TB contact, we had a high suspicion of TB pericarditis.
The pericardial fluid is usually a yellow-citrus-like exudate with increased lymphocyte numbers and low glucose. Their culture is not always positive. If it is not effectively emptied, it will result in the formation of fibrins, septations and granulomas with adherence and thickening of leaflets evolving to chronic constrictive pericarditis.6
Definite tubercular pericarditis can be diagnosed by one or more of the following criteria: 11
Isolation of M. tuberculosis from pericardial effusion fluid or pericardial biopsy.
Demonstration of granulomatous inflammation on histologic examination of pericardial biopsy sample.
Isolation of M. tuberculosis from sputum or non pericardial effusion exudates in the presence of clinical and/or radiological evidence of tuberculosis, associated with a positive response to antitubercular therapy and in the absence of any other obvious cause for pericarditis.
In our case, the initial planned for pericardiectomy was not carried out, but thoracotomy, pericardial window and biopsy was done. Both pericardial fluid and pleural fluid showed lymphocyte predominant but only pericardial fluid had low glucose level. Eventhough pericardial and pleural fluid culture were negative, pericardial biopsy result showed granulomatous inflammation with giant cells langhans suggestive of tuberculosis.
Laghari & colleagues reported series of 143 surgically confirmed cases of constrictive pericarditis, among them increased pericardial thickness was seen in 37%, and almost all thickened pericardium showed tubercular pericarditis in histopathological examination.7
Prompt treatment of tubercular pericarditis may be lifesaving. Effective treatment requires a rapid and accurate diagnosis, which is often difficult.5 Antibiotic chemotherapy increases survival dramatically in tubercular pericarditis. A regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for at least two months followed by INH and rifampicin (total six months of therapy) have been shown to be highly effective.11
Two issues arise in the treatment of tubercular pericarditis: the use of corticosteroids and the need for open surgical drainage versus pericardiocentesis. The goal of therapy of tubercular pericarditis is not only to treat the acute symptoms of tamponade, but also to prevent progression from the effusive to the constrictive stage, in which a fibrotic and calcified pericardium entraps the heart.10 In early-stage patients with minimal pericardial effusion, pericardiocentesis with biopsy can be done to confirm the diagnosis. If cardiac tamponade develops, creation of a pericardial window should be done. If constrictive pericarditis presents, pericardiectomy is the treatment of choice. The operative mortality for pericardiectomy is around 2.3%. As a poor hemodynamic result after complete pericardiectomy relates to the preoperative degree of constriction and resultant cardiomyopathy. 4
Yang et al. reported their 14 years’ experience, indicating that 37.5% of patients with early-stage TB pericarditis developed constrictive pericarditis, while among patients with advanced-stage disease, 85.7% subsequently developed pericardial constriction. 12
In present case, anti tuberculosis treatment (FDC) was started earlier based on high index suspicion of tuberculosis causing symptomatic constrictive pericarditis and pleuritis. Although thoracotomy and pericardial window had been done initially, but symptoms are minimally improved and repeated echo showed constrictive signs over posterior, lateral and apical segment. Our patient was considered an advanced-stage disease which already developed constrictive pericarditis with stiff pericardium and 1 cm thickness of fibrosis. Pericardiectomy is the treatment of choice, and should had been done earlier. Open procedure sternotomy with pericardiectomy, was finally done to achieve a sustained relief of symptoms. Corticosteroid was then started with 1 mg/ kg body weight to quicken resolution of symptoms and decrease reaccumulation of fluid. It should be given before irreversible constriction has occurred. The patient was responding well to the treatment, with no recurrence of symptoms or any signs of deterioration when last followed up.
This case is a late presentation of extrapulmonary manifestation of pulmonary tuberculosis, which is present as a consequence or, complication of pulmonary tuberculosis. So, early diagnosis and treatment is very much important to prevent late consequence like tubercular constrictive pericarditis.
Conclusions
Clinicians should have a high index of suspicion of TB pericarditis when encountering a patient with pericardial effusion, especially if co-existent pleural effusion is noticed.
The goal of therapy of tubercular pericarditis is not only relief of symptoms, but also to prevent progression from the effusive to the constrictive stage. If constrictive pericarditis presents, pericardiectomy is the treatment of choice.
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