Tuberculous pericarditis
| Tuberculous pericarditis | |
|---|---|
| Specialty | Infectious diseases |
Tuberculous pericarditisis a form ofpericarditis.It is a condition in which thepericardiumsurrounding the heart is infected by the bacterial speciesMycobacterium tuberculosis.[1]Tuberculous pericarditis accounts for a significant percentage of presentations oftuberculosisworldwide.[2]The condition has four stages of disease which manifests with clinical presentations ranging fromacute pericarditisto overtheart failure.[3]Tuberculous pericarditis is an under-diagnosed condition.[3]Diagnosis often requires a range of diagnostic tools, includingpericardiocentesis,biochemical tests, and imaging.[3][4]Treatment of this disease is similar to treatment ofpulmonary tuberculosis.[1][4]Alternative treatment options to reduce cardiac complications are also available.[3][5]
Epidemiology
[edit]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 effusivepericarditisworldwide.[6]In tuberculosis-endemic regions, tuberculous pericarditis accounts for 50-90% of cases of effusive pericarditis, depending onHIVstatus.[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
[edit]Tuberculous pericarditis is caused by infection with the bacterial speciesMycobacterium tuberculosis.[1]Bacteria enter the body through inhalation and are ingested by white blood cells calledmacrophages.[1]Surviving bacteria multiply and can spread to other areas of the body. This can occur through thelymphatic 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 includeIL-10,IL-1β,IL-6,IL-8,interferon-γ induced protein,andtumor necrosis factor.[3]These mediators then accumulate in the pericardial fluid leading to inflammation andfibrosis.[3]Certain individuals have an increased risk of infectious spread to the pericardium. This includes people with immunosuppression,HIV/AIDS,chronic kidney disease,anddiabetes,amongst others.[2][4]
There are four stages of tuberculous pericarditis following infection byMycobacterium tuberculosis:[3]
| Manifestation | Pathological Basis | Clinical Presentation | |
|---|---|---|---|
| Stage 1 | Dry stage |
|
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| Stage 2 | Effusive stage |
|
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| Stage 3 | Adsorptive stage |
|
|
| Stage 4 | Constrictive stage |
|
|
Signs and Symptoms
[edit]Tuberculous pericarditis commonly presents with symptoms similar to both pulmonary tuberculosis and heart failure.[4]These symptoms include:[4]
- Fever
- Fatigue
- Night sweats
- Weight loss
- Shortness of breath
- Chest pain
- Cough
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 extremityedema.[2]The clinical presentation depends on the stage of disease. The dry stage presents with features resembling acute pericarditis (chest pain, pericardial friction rub, diffuseST-segment elevationon 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
[edit]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 culturingMycobacterium tuberculosisfrom aspiratedpericardialfluid.[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, theTygerberg scoring systemhelps 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]
- Fever = 2 points
- Night sweats = 1 point
- Loss of body mass = 1 points
- Globulinlevel > 40 g/L = 3 points
- Peripheralleukocytecount < 10 × 10^9/L = 3 points
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]Echocardiographyis the first-line imaging modality for diagnosis of pericarditis.[4]Chest X-Ray, CT scans, and MRI are also widely used options.[4]
Management
[edit]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 ofrifampin,isoniazid,pyrazinamide,andethambutolfollowed 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 tuberculouspericarditis.[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]Corticosteroidshave long been thought to help reduce the risk of future cardiac complications.[3][7]Colchicineis a drug thought to reduce the recurrence of constrictive pericarditis, although evidence is limited.[5]The use offibrinolyticsandACE inhibitorsare also options to help reduce pericardial fibrosis.[5]Pericardiectomymay be indicated in severe cases,[2]as open surgical drainage of fluid around the heart may reduce risk of future fluid accumulation.[7]
References
[edit]- ^abcdefAgabegi, Steven; Agabegi, Elizabeth; Duncan, Mark; Chuang, Kelley (2023).Step-Up to Medicine(6 ed.). McGraw Hill Professional. pp. 394–451.ISBN9781260460636.
{{cite book}}:CS1 maint: multiple names: authors list (link) - ^abcdeAdefuye, Mayowa A; Manjunatha, Nisha; Ganduri, Vinutna; Rajasekaran, Kruthiga; Duraiyarasan, Shrimahitha; Adefuye, Bolanle O (2022)."Tuberculosis and Cardiovascular Complications: An Overview".Cureus.14(8): e28268.doi:10.7759/cureus.28268.ISSN2168-8184.PMC9491794.PMID36158349.
- ^abcdefghijklmnopqrIsiguzo, Godsent; Du Bruyn, Elsa; Howlett, Patrick; Ntsekhe, Mpiko (2020)."Diagnosis and Management of Tuberculous Pericarditis: What Is New?".Current Cardiology Reports.22(1): 2.doi:10.1007/s11886-020-1254-1.ISSN1523-3782.PMC7222865.PMID31940097.
- ^abcdefghijklmFeger, Joachim."Tuberculous pericarditis | Radiology Reference Article | Radiopaedia.org".Radiopaedia.Retrieved2023-12-04.
- ^abcdefgNaicker, Kishendree; Ntsekhe, Mpiko (April 2020)."Tuberculous pericardial disease: a focused update on diagnosis, therapy and prevention of complications".Cardiovascular Diagnosis and Therapy.10(2): 289–295.doi:10.21037/cdt.2019.09.20.ISSN2223-3652.PMC7225424.PMID32420111.
- ^abcdeDybowska, Małgorzata; Błasińska, Katarzyna; Gątarek, Juliusz; Klatt, Magdalena; Augustynowicz-Kopeć, Ewa; Tomkowski, Witold; Szturmowicz, Monika (March 2022)."Tuberculous Pericarditis—Own Experiences and Recent Recommendations".Diagnostics.12(3): 619.doi:10.3390/diagnostics12030619.PMC8947333.PMID35328173.
- ^abcWiysonge, Charles S.; Ntsekhe, Mpiko; Thabane, Lehana; Volmink, Jimmy; Majombozi, Dumisani; Gumedze, Freedom; Pandie, Shaheen; Mayosi, Bongani M. (13 September 2017)."Interventions for treating tuberculous pericarditis".The Cochrane Database of Systematic Reviews.2017(9): CD000526.doi:10.1002/14651858.CD000526.pub2.ISSN1469-493X.PMC5618454.PMID28902412.