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