TB Pericarditis! 6/25/18

Today, we learned about a young man with no significant medical history who presented with fever of unknown origin, noted to have R sided lymphadenopathy and a pericardial friction rub.  Work up revealed a moderate sized pericardial effusion, a thickened pericardium, and a necrotic LN showing caseating granulomas on biopsy consistent with TB pericarditis!


Clinical Pearls:

  • Most common cause of pericarditis in the west is idiopathic.
  • Indications for pericardiocentesis
    • Tamponade
    • Suspicion for purulent/tuberculous/neoplastic pericarditis
    • Moderate to large pericardial effusions not responding to anti-inflammatory therapy
  • Purulent pericarditis occurs in 1% of infectious cases with staph aureus being the most common underlying pathogen.
  • TB pericarditis:
    • Leading cause of pericarditis in high HIV prevalent and resource limited settings around the world
    • Treatment requires anti-TB medications.  Steroids are not routinely recommended but may benefit high risk populations
    • Leading complication is constrictive pericarditis, early therapy does not decrease likelihood of development.

Pericarditis

Diagnosis: (Requires 2 out of the following 4)

  1. Typical chest pain
  2. Pericardial friction rub
  3. EKG with diffuse ST elevations
  4. TTE with an effusion

Etiology:

  • Idiopathic
    • Primary cause of pericarditis in the west
  • Infectious
    • Viral
      • Coxsackie, EBV, adeno, HIV
    • Bacterial
      • Staph aureus (most common cause), TB, strep pneumo, neisseria, legionella, nocardia
    • Other
      • Toxoplasma
      • Echiconoccus
  • Non-infectious:
    • Neoplastic
      • hematologic malignancies, lung CA, breast CA, melanoma, mesothelioma
    • Metabolic disorders
      • Uremia, hypothyroidism
    • Autoimmune diseases
      • SLE, RA, scleroderma, MCD, sjogren’s, vasculitides
    • Cardiac injury
      • Trauma, MI, post-PCI, post cardiothoracic surgery
    • Drugs
      • INH, doxorubicin

Indications for pericardiocentesis:

  • Tamponade
  • Suspicion for purulent/tuberculous/neoplastic process
  • Moderate to large effusions of unknown etiology that are not improving with conservative management

 TB pericarditis 

  • Diagnosis is often delayed or missed leading to constrictive pericarditis and increased mortality
  • Occurs in 1-2% of patients with pulmonary TB.
  • Symptoms:
    • Cough, dyspnea, CP, fever, night sweats, orthopnea, weight loss
  • Exam
    • Fever
    • Tachycardia
    • Elevated JVP
    • Hepatomegaly
    • Ascites
    • Peripheral edema
    • Friction rub
    • Distant heart sounds
    • Kussmaul’s sign (lack of inspiratory decline in JVP), prominent Y descent, pericardial knock
  • Evaluation
    • TTE
    • Sputum AFB and culture
    • PTB noted on CXR 32-72% of the time
    • Pericardiocentesis indicated for diagnosis but does not reduce likelihood of developing complications or death
      • Send fluid studies for cell count, protein concentration, LDH, AFB smear/culture, GS and bacterial culture, ADA, and cytology
      • Fluid has high protein content and lymphocytic/monocytic leukocytosis
  • Complications
    • Constrictive pericarditis (30-60% of patients) even with prompt therapy, more common in HIV uninfected individuals
    • Effusive constrictive pericarditis
    • Myopericarditis
    • Cardiac tamponade
  • Treatment:
    • Anti-TB therapy
    • Steroids?
      • Not routinely recommended and do not consistently prevent complications
      • Could consider in high risk groups with early signs of constriction
    • Pericardiectomy for those with persistent constriction

 

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