Case Reports Acta Cardiol Sin 2007;23:56-61

Acute Primary Tuberculous

Hsien-Kuo Chin, Yee-Phoung Chang and Chia-Shen Chao

Acute primary tuberculous (TB) pericarditis is a rare but life-threatening condition. It may lead to diastolic in constrictive pericarditis. A 77-year-old man suffered from exertional dyspnea for 3 weeks. He had received percutaneous transluminal coronary angioplasty (PTCA) with stent for left anterior descending artery lesion 3 weeks prior to this admission. As dyspnea on exertion persisted, he was admitted to our hospital for possible coronary arterial bypass grafting. No significant in-stent restenosis was found during recatheterization. Meanwhile, bilateral pleural effusions were found, but they were negative for TB cultures and polymerase chain reaction (PCR). Thickening of with large amount of was noted during echocardiographic examination 3 weeks after admission. Emergent pericardiotomy was done for and biopsy. Acute primary TB pericarditis was diagnosed and antituberculous chemotherapy plus adjuvant corticosteroid treatment were given. The patient was discharged 2 weeks later in fair condition. Unfortunately, one month later he was readmitted due to constrictive pericarditis. Pericardiectomy was done. After a full course of anti-TB therapy for 9 months, the patient kept well after follow-up for one year.

Key Words: Cardiac tamponade · Corticosteroid · Pericardiectomy · Primary tuberculous pericarditis

INTRODUCTION ever, the incidence of TB in Taiwan remains high. Ac- cording to a report from the Center for Disease Control Acute pericarditis1 (< 3 months) is dry, fibrinous or of Taiwan in 2002, the incidence and mortality rate of effusive, independent of its etiology. Most cases of acute TB were 74.6 and 5.68 per 100,000 population, respec- pericarditis are viral or idiopathic. Other causes are un- tively.2 Pulmonary involvement accounted for 77.8% of common, including bacterial infection, , ur- cases, with TB and isolated extra-pulmonary involve- emic pericarditis, , previous cardiac ment only accounting for 22%.3 Cardiac tamponade and surgery, complication after radiotherapy, cancer, and in- constrictive pericarditis are major lethal complications flammatory diseases, etc. Each year, there are approxi- of TB pericarditis.4 Apart from antituberculous chemo- mately 9 million new cases of tuberculosis worldwide, therapy with/without corticosteroid therapy, pericar- and 3 million die from the disease. Tuberculosis (TB) is diectomy may be the optimal therapy for TB pericarditis. a serious problem in developing countries, which ac- As the incidence of TB in Taiwan remains high and the count for 95% of worldwide TB cases, and 99% of symptoms of TB pericarditis are nonspecific, a high sus- worldwide TB mortality. TB has not been on the list of picion of TB pericarditis should always be kept in mind the leading causes of death in Taiwan since 1985. How- when encountering a patient with pericardial effusion.

Received: September 12, 2006 Accepted: December 14, 2006 CASE REPORT Division of Cardiovascular Surgery, Department of Surgery, Kao- hsiung Armed Forces General Hospital, Kaohsiung, Taiwan. Address correspondence and reprint requests to: Dr. Chia-Shen A 77-year-old man, a retired bank manager, suffered st Chao, No. 2, Chung-Cheng 1 Road, Kaohsiung 802, Taiwan. from chest oppression about 3 weeks prior to this admis- Tel: 886-7-749-4963; Fax: 886-7-749-3207; E-mail: cvschin@yahoo. com.tw sion. Percutaneous transluminal coronary angioplasty

Acta Cardiol Sin 2007;23:56-61 56 Acute Primary Tuberculous Pericarditis with stent for left anterior descending artery lesion was circumflex coronary artery & right coronary artery were done under the diagnosis of with found in cardiac catheterization. Proximal LAD 50% congestive heart failure at another hospital three weeks narrowing was the same as previous. The symptoms im- previous. But exertional dyspnea persisted. Under the proved after the use of inotropic agents. Intermittent low suspicion of in-stent restenosis, the patient was admitted grade fever (37~38 °C) was found during hospitaliza- to our hospital for possible coronary arterial bypass tion, but there were negative results in all the cultures of grafting surgery on June 13, 2005. sputum, pleural effusion and blood. The patient had had history of hypertension and dia- On July 6, a follow-up echocardiography revealed betic mellitus for more than 10 years, and he had been severe hypokinesia of the right ventricle (RV) free wall taking medication regularly. He had no habit of smoking with preserved LV systolic function. Tumor of the pe- or drinking. Poor appetite, malaise and loss of body ricardium with large pericardial effusion was noted, too. weight were noted in recent weeks. No fever was found. Thickening of the pericardium was confirmed in a chest There was no jugular vein engorgement. Bilateral basal computed tomography (Figure 2). Pericardial window rales of lungs and pitting edema of both legs were noted. thru minimal thoracotomy was arranged. Unfortunately, On the day of admission, echocardiography revealed im- cardiac tamponade occurred (blood pressure: 80/50 paired left ventricle (LV) systolic function. Bilateral mmHg, heart rate: 138/min and respiratory rate: 30/min, blunt costophrenic angles (left side more prominent than SpO2: 87%), emergent pericardiotomy via subxyphoid the right) were noted on chest radiography (Figure 1). approach was done. Caseous-like turbid fluid, about 150 Hepatic vein and inferior vena cava engorgement was cc, was drained (Figure 3). Bilateral thoracic intubations noted in abdominal sonography. Pulmonary hypertension (pulmonary arterial pressure: 41/23 mmHg), high central venous pressure (21 mmHg) and low cardiac index (1.81 L/min/m2) were found after Swan-Ganz catheterization measurement. No in-stent restenosis and patency of left

Figure 2. Chest computed tomography revealed thickened pericardium, large amount of pericardial effusion with right ventricle compression and bilateral pleural effusions (left side more prominent than the right).

Figure 1. Chest radiography, performed on the day of admission, showed bilateral blunt costophrenic angles (left side more severe than Figure 3. Pleural effusion (A) revealed light yellowish color, while the right). pericardial effusion (B) was caseous-like turbid fluid.

57 Acta Cardiol Sin 2007;23:56-61 Hsien-Kuo Chin et al. were performed, and a large amount of clear transudate was drained. The vital signs became stable after the pro- cedures. The patient was sent to intensive care unit for recovery. The systolic function of RV and LV were found normal by echocardiography 2 weeks later. Numerous acid-fast bacilli were identified in the specimen from the pericardium (Figure 4). The TB- polymerase chain reaction (PCR) test of pericardial effu- sion was positive. Negative finding of acid-fast stain in sputum and pleural effusion was found. The TB-PCR Figure 4. Numerous acid-fast bacilli were identified from pericardial test was negative, too. Cultures of sputum and pleural ef- material tissue under microscope. fusion also yielded negative findings. Four combined antituberculous chemotherapy (EMB 800 mg + isoniazid 320 mg + pyrazinamide 1000 mg + rifampin 480 mg per day) plus adjuvant corticosteroid therapy (prednisolone 60 mg per day) were given. The fever subsided on the next day of regimen. The patient was discharged in good condition. Dyspnea on exertion (New York Heart As- sociation Function Class II~III) developed again one month later. He was re-admitted to our ward under the impression of constrictive pericarditis on September 5, 2005. Pericardiectomy was done (Figure 5). Numerous acid-fast bacilli were found in the excised pericardium. Figure 5. Thickened pericardium with fibrotic change and some The symptom of exertional dyspnea was absent after calcification. pericardiectomy. After a full course of anti-TB therapy for 9 months, the patient kept well after one year fol- low-up. carditis in one previous report,4 but this was not seen in our patient. Although isolated extra-pulmonary involve- ment only accounted for 22% of cases with TB, pleural DISCUSSION effusion was found in 63% of cases with TB pericardtis.5 Clinicians should have a high index of suspicion of TB The incidence and mortality of TB pericarditis in de- pericarditis when encountering a patient with pericardial veloping countries are still high. The mortality rate in effusion in Taiwan, especially if co-existent pleural effu- untreated acute effusive TB pericarditis can approach up sion is noticed. to 85%,1 and was reduced to 3~11% in patients5 who re- The diagnosis is made by the identification of Myco- ceived oral medication. In Taiwan, the incidence of bacterium tuberculosis in the pericardial fluid or tissue, tuberculosis has remained high in recent years. The cli- and/or the presence of caseous granulomas in the pe- nical manifestations in patients with TB pericarditis ricardium.6 PCR can identify DNA of usually are nonspecific. Dyspnea, jugular vein disten- tuberculosis rapidly from only 1 mL of pericardial fluid.7 sion, fever (usually < 39 °C), cough, tachycardia, leg High adenosine deaminase activity and interferon gam- edema and chest tightness or pain were the most com- ma concentration in pericardial effusion are also di- monly found clinical manifestations.5 Combined intra- agnostic. Pericardial biopsy enables rapid diagnosis with and extrapulmonary TB had a significantly higher in- better sensitivity than pericardiocentesis (100 vs. 33%). cidence of high fever and a longer duration of fever. Various antituberculous drug combinations and treat- Low-voltage QRS and inverted T-waves were the cha- ment duration of different lengths (6, 9, 12 months) have racteristic findings of electrocardiogram in TB peri- been applied.4,8-10 Although corticosteroids are capable

Acta Cardiol Sin 2007;23:56-61 58 Acute Primary Tuberculous Pericarditis of suppressing inflammatory reaction in TB pericar- myopathy,16 the long-term survival after pericardiectomy ditis,4,10 the use of corticosteroids will inevitably further for constrictive pericarditis is related to LV systolic compromise the immunity in vulnerable elderly suffer- function, renal function and pulmonary artery pressure;17 ing from TB pericarditis.4 Despite the use of steroids early pericardiectomy is recommended when constrictive remaining controversial, a meta analysis of patients with pericarditis is diagnosed, or when conditions suggests a effusive and constrictive TB pericarditis11,12 suggested high possibility of developing constrictive pericarditis.18 that tuberculosis treatment combined with steroids might In conclusion, clinicians in Taiwan should maintain be associated with fewer deaths,13 and less frequent need a high index of suspicion for TB pericarditis when a for pericardiocentesis or pericardiectomy.10,14 In our pa- patient develops an unexpected pericardial effusion. De- tient, the fever subsided rapidly after the use of pred- spite the use of steroids remaining controversial, tubercu- nisolone. High-dose prednisolone (1-2 mg/kg per day) losis treatment combined with steroids is recommended should be given, since rifampicin induces its liver me- if no clear contraindication is present. In patients with tabolism. The dose is maintained for 5-7 days and is advanced-stage TB, if there is cardiac tamponade in the progressively tapered to discontinue in 6-8 weeks.1 early clinical stage, or if severe fibrosis of the peri- Since cardiac tamponade and constrictive pericar- cardium and constrictive pericarditis develop, early pe- ditis are two major lethal complications of TB peri- ricardiectomy will be the optimal treatment. carditis, can we predict or prevent these conditions? Based on the echocardiographic findings, TB peri- carditis has been categorized into: (1) early stage, when REFERENCES only pericardial effusion is found, and (2) advanced stage, when fibrin strand formation or fibrosis with 1. Bernhard M, Petar MS, Arsen DR, et al. Guidelines on the Diagnosis and Management of Pericardial Diseases. Executive thickening of pericardium reflecting constrictive peri- summary. The Task Force on the Diagnosis and Management of carditis is detected. An early report indicated that car- Pericardial Diseases of the European Society of Cardiology. Eur diac tamponade developed in approximately 50% of Heart J 2004;25:587-610. patients who did not received adequate treatment in the 2. Center for Disease Control Taiwan, R.O.C. Available at: URL: first 3 months after the diagnosis of TB pericarditis.5 http//203.65.7.83/ch/dt/Show Publication.ASP Yang et al. reported their 14 years’ experience, in- 3. Lin YS, Huang YC, Chang LY et al. Clinical characteristics of dicating that 37.5% of patients with early-stage TB pe- tuberculosis in children in the north of Taiwan. J Microbiol Immunol Infect 2005;38:41-6. ricarditis developed constrictive pericarditis, while 4. Fowler NO. Tuberculous pericarditis. JAMA 1991;266(1):99- among patients with advanced-stage disease, 85.7% 103. 5 subsequently developed pericardial constriction. From 5. Yang CC, Lee MH, Liu JW, et al. Diagnosis of tuberculous the study of Suwan and Potjalongsilp, cardiac tam- pericarditis and treatment without corticosteroids at a tertiary ponade in the early stage of TB pericarditis was the teaching hospital in Taiwan: a 14-year experience. J Microbiol most predictive factor for subsequent constrictive pe- Immuno Infect 2005;38:47-52. ricarditis,12 and the degree of fibrosis of pericardium 6. Spodick DH. Infectious pericarditis. In: Spodick DH, Ed. The pericardium: a comprehensive textbook. New York: Marcel before treatment was the most important determinant of Dekker; 1997. p. 260-90. 15 developing constriction. 7. Seino Y, Ikeda U, Kawaguchi K, et al. Tuberculosis pericarditis In early-stage patients with minimal pericardial effu- presumably diagnosed by polymerise chain reaction analysis. Am sion, pericardiocentesis with biopsy can be done to Heart J 1993;126:249-51. confirm the diagnosis. If cardiac tamponade develops, 8. Koh KK, Kim EJ, Cho CH, et al. Adenosine deaminase and creation of a pericardial window should be done. If con- carcinoembryonic antigen in pericardial effusion diagnosis, strictive pericarditis presents, pericardiectomy is the especially in suspected tuberculous pericarditis. Circulation 1994;89(6):2728-35. treatment of choice. The operative mortality for peri- 9. Sagrista-Sauleda J, Permanyer-Miralda G, Soler-Soler J. Tu- cardiectomy is around 2.3%. As a poor hemodynamic berculous pericarditis: ten year experience with a prospective result after complete pericardiectomy relates to the pre- protocol for diagnosis and treatment. J Am Coll Cardiol 1988; operative degree of constriction and resultant cardio- 11(4):724-8.

59 Acta Cardiol Sin 2007;23:56-61 Hsien-Kuo Chin et al.

10. Strang JI, Kakaza HH, Gibson DG, et al. Controlled clinical trial 14. Strang JI. Rapid resolution of tuberculous pericardial effusion of complete open surgical drainage and of prednisolone in with high dose prednisone and antituberculous drugs. J Infect treatment of tuberculous pericardial effusion in Transkei. Lancet 1994;28:251-4. 1988;2(8614):759-64. 15. Suwan PK, Potjalongsilp S. Predictors of constrictive pericarditis 11. Mayosi BM, Ntsekhe M, Volmink JA, et al. Interventions for after tuberculous pericarditis. Br Heart J 1995;73(2):187-9. treating tuberculous pericarditis. Cochrane Database Syst Rev 16. McCaughan BC, Schaff HV,Pihler JM, et al. Early and late results 2002;(4):CD000526. of pericardiectomy for constrictive pericarditis. J Thorac Car- 12. Ntsekhe M, Wiysonge C, Volmink JA, et al. Adjuvant cor- diovasc Surg 1985;89(3):340-50. ticosteroids for tuberculous pericarditis: promising, but not pro- 17. Bertog SC, Thambidorai SK, Parakh K, et al. Constrictive pe- ven. Q J Med 2003;96:593-9. ricarditis: etiology and cause-specific survival after pericar- 13. Strang JI, Nunn AJ, Johnson DA, et al. Management of tu- diectomy. J Am Coll Cardiol 2004;43(8):1445-52. berculous constrictive pericarditis and tuberculous pericardial 18. Bashi VV, John S, Ravikumar E, et al. Early and late results of effusion in Transkei: results at 10 years follow-up. Q J Med pericardiectomy in 118 cases of constrictive pericarditis. Thorax 2004;97(8):525-35. 1988;43(8):637-41.

Acta Cardiol Sin 2007;23:56-61 60 Case Reports Acta Cardiol Sin 2007;23:56−61

急性原發性結核心包膜炎

金憲國 張一方 趙家聲 高雄市 國軍高雄總醫院 外科部 心臟血管外科

急性原發性結核心包膜炎是一十分罕見但卻致命的一種狀況，它通常導致侷限性心包膜炎 進而造成舒張性心衰竭。我們報告一位 77 歲男性在住院前三個月因冠心症合併心衰竭接受 左前降支支架置放術。後因氣喘而到本院求診，要求進行冠狀動脈繞道手術。心導管攝影 顯示除左前降支之支架外無明顯病兆。住院後反覆有兩側肋膜積水，積水之所有結核檢查 皆呈陰性。 3 週後於心臟超音波檢查發現心包膜有增厚情形且合併大量心包膜液，因為造 成心包填塞而從劍突施予緊急心包膜切開術。經組織病理診斷為急性原發性結核心包膜炎， 我們給予抗結核菌藥物合併類固醇輔助治療後病情明顯好轉並於幾天後出院。病患於一個 月後因侷限性心包膜炎而施予心包膜截除術。病患在九個月的抗結核藥物治療後，追蹤至 今滿一年仍保持良好狀態。

關鍵詞：心包填塞、類固醇、心包膜截除術、原發性結核心包膜炎。

61