Tuberculous pericarditis

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Tuberculous pericarditis
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Tuberculous pericarditis is a form of pericarditis. It is a condition in which the pericardium surrounding the heart is infected by the bacterial species Mycobacterium tuberculosis . [1] Tuberculous pericarditis accounts for a significant percentage of presentations of tuberculosis worldwide. [2] The condition has four stages of disease which manifests with clinical presentations ranging from acute pericarditis to overt heart failure. [3] Tuberculous pericarditis is an under-diagnosed condition. [3] Diagnosis often requires a range of diagnostic tools, including pericardiocentesis, biochemical tests, and imaging. [3] [4] Treatment of this disease is similar to treatment of pulmonary tuberculosis. [1] [4] Alternative treatment options to reduce cardiac complications are also available. [3] [5]

Contents

Epidemiology

Tuberculous pericarditis is a condition that accounts for 1-2% of presentations of tuberculosis outside of the lungs. [2] It is found in people of all ages and typically affects males more frequently than females. [4] Tuberculosis is also one of the leading causes of effusive pericarditis worldwide. [6] In tuberculosis-endemic regions, tuberculous pericarditis accounts for 50-90% of cases of effusive pericarditis, depending on HIV status. [6] In developed countries, it only accounts for about 4% of cases. [6] Tuberculous pericarditis is a deadly disease with a mortality rate of up to 40% in the first 6 months after diagnosis. [6]

Pathogenesis

Tuberculous pericarditis is caused by infection with the bacterial species Mycobacterium tuberculosis. [1] Bacteria enter the body through inhalation and are ingested by white blood cells called macrophages. [1] Surviving bacteria multiply and can spread to other areas of the body. This can occur through the lymphatic system, blood, or via direct spread from infected tissues. [1] [3] Infection of the pericardium is assisted by a variety of inflammatory and fibrotic mediators. These mediators include IL-10, IL-1β, IL-6, IL-8, interferon-γ induced protein, and tumor necrosis factor. [3] These mediators then accumulate in the pericardial fluid leading to inflammation and fibrosis. [3] Certain individuals have an increased risk of infectious spread to the pericardium. This includes people with immunosuppression, HIV/AIDS, chronic kidney disease, and diabetes, amongst others. [2] [4]

There are four stages of tuberculous pericarditis following infection by Mycobacterium tuberculosis: [3]

ManifestationPathological BasisClinical Presentation
Stage 1Dry stage
  • Fibrinous exudation
  • Abundant mycobacteria
  • Granuloma formation
  • Acute pericarditis
Stage 2Effusive stage
  • Lymphocytic exudation
  • Serosanguineous effusion
Stage 3Adsorptive stage
  • Absorption of effusion
  • Pericardial thickening
  • Fibrosis
  • Constrictive pericarditis
Stage 4Constrictive stage
  • Constructive scarring
  • Calcification of pericardium
  • Constrictive pericarditis

Signs and Symptoms

Tuberculous pericarditis commonly presents with symptoms similar to both pulmonary tuberculosis and heart failure. [4] These symptoms include: [4]

Indications of pericarditis or heart failure may also be seen on physical exam. These signs include increased heart rate, decreased blood pressure, pericardial friction rub, ascites, and lower extremity edema. [2] The clinical presentation depends on the stage of disease. The dry stage presents with features resembling acute pericarditis (chest pain, pericardial friction rub, diffuse ST-segment elevation on EKG, etc.). [4] The effusive, adsorptive, and constrictive stages typically present with features of heart failure (shortness of breath, ascites, peripheral edema, etc.). [4]

Diagnosis

Tuberculous pericarditis is an under-diagnosed condition with up to 15-20% of people with the disease never being formally diagnosed. [3] It is difficult to diagnose because definitive diagnosis requires culturing Mycobacterium tuberculosis from aspirated pericardial fluid. [4] This can be achieved via pericardiocentesis, which has both therapeutic and diagnostic utility. [3] Pericardial biopsy is another method of obtaining samples, although this method is invasive and is used less frequently. [5] [6] Culturing pericardial fluid is currently the most widely used diagnostic test for tuberculous pericarditis. [3] However, this process is lengthy and may take up to 3 weeks to receive results. [3] Biochemical tests are another method for diagnosis, as these are much less time consuming. Adenosine deaminase (ADA) is the most widely used biochemical test. [3] Other options include Xpert MTB/RIF and IFN-γ, but these tests are costly and therefore less available. [3]

When collecting pericardial fluid is not possible, the Tygerberg scoring system helps the clinician to decide whether pericarditis is due to tuberculosis or another cause. [5] In tuberculosis-endemic regions, ≥6 points is highly predictive of tuberculous pericarditis: [5]

Radiography is another method used to aid in the diagnosis of tuberculous pericarditis. This imaging can help identify effusions, calcifications, and thickening around the heart. [4] Echocardiography is the first-line imaging modality for diagnosis of pericarditis. [4] Chest X-Ray, CT scans, and MRI are also widely used options. [4]

Management

There are three main goals in the management of tuberculous pericarditis. These goals are to kill the active infection, reduce heart strain and associated symptoms, and prevent future cardiac complications. [3] Elimination of the infection is through the same therapy used in pulmonary tuberculosis. This therapy consists of a 2-month regimen of rifampin, isoniazid, pyrazinamide, and ethambutol followed by 4-months of rifampin and isoniazid. [1] [4] However, recent research has yet to evaluate the definitive length of anti-tuberculosis treatment required for tuberculous pericarditis. [7] Reducing heart strain and improving symptoms is achieved primarily through pericardiocentesis. [3] This procedure helps to reduce fluid accumulation around the heart. [3] Constrictive pericarditis is the main long-term complication of tuberculous pericarditis that requires management. [5] Corticosteroids have long been thought to help reduce the risk of future cardiac complications. [3] [7] Colchicine is a drug thought to reduce the recurrence of constrictive pericarditis, although evidence is limited. [5] The use of fibrinolytics and ACE inhibitors are also options to help reduce pericardial fibrosis. [5] Pericardiectomy may be indicated in severe cases, [2] as open surgical drainage of fluid around the heart may reduce risk of future fluid accumulation. [7]

Related Research Articles

<span class="mw-page-title-main">Pericardium</span> Double-walled sac containing the heart and roots of the great vessels

The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue, and an inner layer made of serous membrane. It encloses the pericardial cavity, which contains pericardial fluid, and defines the middle mediastinum. It separates the heart from interference of other structures, protects it against infection and blunt trauma, and lubricates the heart's movements.

<span class="mw-page-title-main">Cardiac tamponade</span> Buildup of fluid around the heart

Cardiac tamponade, also known as pericardial tamponade, is a compression of the heart due to pericardial effusion. Onset may be rapid or gradual. Symptoms typically include those of obstructive shock including shortness of breath, weakness, lightheadedness, and cough. Other symptoms may relate to the underlying cause.

<span class="mw-page-title-main">Pleurisy</span> Disease of the lungs

Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever, or weight loss, depending on the underlying cause. Pleurisy can be caused by a variety of conditions, including viral or bacterial infections, autoimmune disorders, and pulmonary embolism.

<span class="mw-page-title-main">Constrictive pericarditis</span> Medical condition

Constrictive pericarditis is a condition characterized by a thickened, fibrotic pericardium, limiting the heart's ability to function normally. In many cases, the condition continues to be difficult to diagnose and therefore benefits from a good understanding of the underlying cause.

<span class="mw-page-title-main">Pericarditis</span> Medical condition

Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sitting up and more severe when lying down or breathing deeply. Other symptoms of pericarditis can include fever, weakness, palpitations, and shortness of breath. The onset of symptoms can occasionally be gradual rather than sudden.

<span class="mw-page-title-main">Pericardiocentesis</span> Procedure where fluid is aspirated from the pericardium

Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium.

Dressler syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium. It consists of fever, pleuritic pain, pericarditis and/or pericardial effusion.

<span class="mw-page-title-main">Tuberculosis management</span>

Tuberculosis management describes the techniques and procedures utilized for treating tuberculosis (TB) or simply a treatment plan for TB.

<span class="mw-page-title-main">Tuberculous lymphadenitis</span> Medical condition

Peripheral tuberculous lymphadenitis is a form of tuberculosis infection occurring outside of the lungs. In general, it describes tuberculosis infection of the lymph nodes, leading to lymphadenopathy. When cervical lymph nodes are affected, it is commonly referred to as "Scrofula." A majority of tuberculosis infections affect the lungs, and extra-pulmonary tuberculosis infections account for the remainder; these most commonly involve the lymphatic system. Although the cervical region is most commonly affected, tuberculous lymphadenitis can occur all around the body, including the axillary and inguinal regions.

<span class="mw-page-title-main">Pericardial effusion</span> Medical condition

A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of the serous membrane enclose the pericardial cavity between them. This pericardial space contains a small amount of pericardial fluid, normally 15-50 mL in volume. The pericardium, specifically the pericardial fluid provides lubrication, maintains the anatomic position of the heart in the chest, and also serves as a barrier to protect the heart from infection and inflammation in adjacent tissues and organs.

<i>Mycobacterium avium-intracellulare</i> infection Medical condition

Mycobacterium avium-intracellulare infection (MAI) is an atypical mycobacterial infection, i.e. one with nontuberculous mycobacteria or NTM, caused by Mycobacterium avium complex (MAC), which is made of two Mycobacterium species, M. avium and M. intracellulare. This infection causes respiratory illness in birds, pigs, and humans, especially in immunocompromised people. In the later stages of AIDS, it can be very severe. It usually first presents as a persistent cough. It is typically treated with a series of three antibiotics for a period of at least six months.

<span class="mw-page-title-main">Pericardial fluid</span>

Pericardial fluid is the serous fluid secreted by the serous layer of the pericardium into the pericardial cavity. The pericardium consists of two layers, an outer fibrous layer and the inner serous layer. This serous layer has two membranes which enclose the pericardial cavity into which is secreted the pericardial fluid. The fluid is similar to the cerebrospinal fluid of the brain which also serves to cushion and allow some movement of the organ.

<span class="mw-page-title-main">Acute pericarditis</span> Medical condition

Acute pericarditis is a type of pericarditis usually lasting less than 6 weeks. It is the most common condition affecting the pericardium.

<span class="mw-page-title-main">Tuberculous meningitis</span> Medical condition

Tuberculous meningitis, also known as TB meningitis or tubercular meningitis, is a specific type of bacterial meningitis caused by the Mycobacterium tuberculosis infection of the meninges—the system of membranes which envelop the central nervous system.

Pericardiectomy is the surgical removal of part or most of the pericardium. This operation is most commonly used to relieve constrictive pericarditis, or to remove a pericardium that is calcified and fibrous. It may also be used for severe or recurrent cases of pericardial effusion. Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

<span class="mw-page-title-main">Hemopericardium</span> Medical condition

Hemopericardium refers to blood in the pericardial sac of the heart. It is clinically similar to a pericardial effusion, and, depending on the volume and rapidity with which it develops, may cause cardiac tamponade.

<span class="mw-page-title-main">Pericardial cyst</span>

A pericardial cyst is an uncommon benign dilatation of the pericardial sac surrounding the heart. It can lead to symptoms by compressing nearby structures, but is usually asymptomatic. Pericardial cysts can be congenital or acquired, and they are typically diagnosed with radiologic imaging. Management of pericardial cysts can include follow-up imaging, percutaneous aspiration, or surgical resection.

<span class="mw-page-title-main">Purulent pericarditis</span> Inflammation of the sac surrounding the heart due to bacterial infection.

Purulent pericarditis refers to localized inflammation in the setting of infection of the pericardial sac surrounding the heart. In contrast to other causes of pericarditis which may have a viral etiology, purulent pericarditis refers specifically to bacterial or fungal infection of the pericardial sac. Clinical etiologies of purulent pericarditis may include recent surgery, adjacent infection, trauma, or even primary infection. The onset of purulent pericarditis is usually acute, with most individuals presenting to a medical facility approximately 3 days following the onset of symptoms.

<span class="mw-page-title-main">Chronic meningitis</span> Inflammation of the membranes surrounding the brain and spinal cord lasting longer than 4 weeks

Chronic meningitis is a long-lasting inflammation of the membranes lining the brain and spinal cord. By definition, the duration of signs, symptoms and inflammation in chronic meningitis last longer than 4 weeks. Infectious causes are a leading cause and the infectious organisms responsible for chronic meningitis are different than the organisms that cause acute infectious meningitis. Tuberculosis and the fungi cryptococcus are leading causes worldwide. Chronic meningitis due to infectious causes are more common in those who are immunosuppressed, including those with HIV infection or in children who are malnourished. Chronic meningitis sometimes has a more indolent course than acute meningitis with symptoms developing more insidiously and slowly. Also, some of the infectious agents that cause chronic infectious meningitis such as mycobacterium tuberculosis, many fungal species and viruses are difficult to isolate from the cerebrospinal fluid making diagnosis challenging. No cause is identified during initial evaluation in one third of cases. Magnetic resonance imaging (MRI) of the brain is more sensitive than computed tomography and may show radiological signs that suggest chronic meningitis, however no radiological signs are considered pathognomonic or characteristic. MRI is also normal in many cases further limiting its diagnostic utility.

References

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