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Redalyc.Tuberculous Pericarditis: Experience in a Community Hospital Autopsy and Case Reports E-ISSN: 2236-1960 [email protected] Hospital Universitário da Universidade de São Paulo Brasil Ferraz de Campos, Fernando Peixoto; Felipe-Silva, Aloísio; Gomes Fonseca, Leonardo; Fernando Seguro, Luiz; Barros de Azevedo Filho, Antônio Fernando Tuberculous pericarditis: experience in a community hospital Autopsy and Case Reports, vol. 1, núm. 1, enero-marzo, 2011, pp. 3-12 Hospital Universitário da Universidade de São Paulo São Paulo, Brasil Available in: http://www.redalyc.org/articulo.oa?id=576060809002 How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative ARTICLE ARTIGO Tuberculous pericarditis : experience in a community hospital Fernando Peixoto Ferraz de Camposa, Aloísio Felipe-Silvab, Leonardo Gomes Fonsecac, Luiz Fernando Segurod, Antônio Fernando Barros de Azevedo Filhoc Campos FPF, Felipe-Silva A, Fonseca LG, Seguro LF, Azevedo Filho AFB. Tuberculous pericarditis: experience in a community hospital. Autopsy Case Rep [Internet]. 2011;1(1):3-12. ABSTRACT Tuberculosis is a major public health problem worldwide. In Butantan district of São Paulo city, the average incidence over the last 7 years was 47.7 new cases/100,000 inhabitants. Tuberculous pericarditis is a serious form of extra- pulmonary tuberculosis in which diagnosis is often difficult. Diagnosis needs to be reached fast and accurately once tuberculous pericarditis has high morbimor- tality rates if untreated. We report the experience of a community hospital on tu- berculous pericarditis with emphasis on the clinical presentation and diagnostic procedures. From 2003 to 2010, 59 patients were diagnosed with pericarditis, 6 (10.16%) of which had tuberculous pericarditis. Demographic, clinical, imaging, laboratorial, microbiological and histological data were reviewed. There were 4 female (66.7%) and 2 male (33.3%) patients. Age ranged from 17 to 62 years (median= 25.5). One patient (17%) had HIV co-infection. Five patients (83.3%) had cardiac tamponade on Echocardiogram. Histopathology was confirmatory in 4 cases (66.7%) while cultures were positive in 2 cases (33.3%). Four patients (66.7%) had definite and 2 (33.3%) had probable diagnosis of tuberculous peri- carditis. One patient (17%) died during admission. Reuter´s diagnostic index was ≥6 in 5 patients (83.3%). We concluded that the clinical picture, Reuter´s diagnostic index, signs of cardiac tamponade on Echocardiogram and the peri- cardium biopsy were the most important features for the diagnosis of tubercu- lous pericarditis. Keywords: Tuberculosis; Pericarditis; Pericarditis, tuberculous; Diagnosis. a Department of Internal Medicine of the Hospital Universitário – Universidade de São Paulo, São Paulo/SP, Brazil. b Service of Anatomic Pathology of the Hospital Universitário – Universidade de São Paulo, São Paulo/SP, Brazil. c Department of Internal Medicine of the Hospital das Clínicas – Faculdade de Medicina, Universidade de São Paulo, São Paulo/ SP, Brazil. d Instituto do Coração – Hospital das Clínicas – Faculdade de Medicina Universidade de São Paulo, São Paulo/SP, Brazil. Copyright © 2011 Autopsy and Case Reports – This is an Open Access article distributed of terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/licenses/by/3.0/ ) which permits unrestricted non-commercial use, distribution, and reproduction in any médium provided article is properly cited. 3 Campos FPF, Felipe-Silva A, Fonseca LG, Seguro LF, Azevedo Filho AFB. INTRODUCTION The tuberculous pericarditis is classified as definite or probable according to one or more of the Tuberculosis is a major public health problem following criteria: worldwide. It is estimated that about 4 to 10 million new cases occur per year, with 1 million deaths.1 Definite when there is: (1) isolation of My- According to the World Health Organization, the in- cobacterium tuberculosis of the pericardial effu- cidence of the disease is stable in developed coun- sion or fragment of biopsy (presence of Acid-fast tries, after a period of growth observed in the 90´s. bacilli (AFB) in the Ziehl-Neelsen staining or posi- However, the global incidence increases around 1% tive culture in the fragment); or (2) demonstration a year, especially because of its growth in regions of of granulomas in the histological exam of the peri- poor socioeconomic conditions, where co-infection cardial biopsy. by the HIV confers high rates of morbimortality to the disease.2 Probable when there is: (1) evidence of peri- carditis in patients with tuberculosis demonstrated The incidence in Brazil between the years in any other site; (2) pericardial effusion character- of 1990-2001 ranged from 75,000-85,000 new ized by exudate with high Adenosine Deaminase cases/year, falling to 60,000 new cases in 2002, (ADA) activity and/or (3) good response to antitu- which represents an incidence coefficient of 50 to berculous chemotherapy, in the absence of any 99/100,000 inhabitants.3 Some countries in Africa other obvious cause for the pericardial effusion.8 present a coefficient of 300 or more and in the USA Tuberculous pericarditis is a form of extra pulmo- and Canada this coefficient is 10. In the state of nary tuberculosis of considerable gravity, with a São Paulo, 15,344 new cases were recorded in mortality rate of 85% in 6 months if untreated9, and 2009, and the annual average between 2004 and of 3% to 40% when treated.10 Therefore, the diag- 2009 was 16,121 new cases per year. In São Pau- nosis should be accurate and fast. However, this is lo city 5,777 new cases of tuberculosis were re- often difficult due to the low sensitivity in detecting corded in 2009, and the average of the previous 5 mycobacterium in samples, slowness in growing years was 6,140 new cases per year. In the district mycobacterium in cultures and to the need for in- of Butantan, where the Hospital Universitário da vasive techniques, which often require specialized Universidade de São Paulo (HU-USP) is located, personnel and centers. 1,274 new cases of tuberculosis were recorded from 2003 to 2010, with an average incidence co- PATIENTS AND METHODS efficient of 47.7/100,000 inhabitantse. Data from patients discharged between The current epidemiologic scenario of the January 2003 and December 2010 with diagnosis disease, considering the advance of HIV infection of pericarditis and/or tuberculosis were recovered and other forms of immunosuppression, and the in- from hospital epidemiological information service creasing incidence in populations with poor health and from the records of the Internal Medicine infir- conditions worldwide, stresses the importance of mary. Fifty nine patients with pericarditis and 87 pa- extra pulmonary forms of tuberculosis, among which tients with tuberculosis were identified. Six patients the Tuberculous Pericarditis. had tuberculous pericarditis (10.16% of pericarditis cases and 6.9% of tuberculosis cases). From these Tuberculous pericarditis is a rare form of six cases, 4 (66.7%) had definite diagnosis of tu- extra pulmonary tuberculosis. Data from the 60´s berculous pericarditis and 2 (33.3%) had probable showed tuberculous pericarditis in 0.4 to 1.1% of all tuberculous pericarditis. autopsies, and in 7.3 to 11% of the cases with acute pericarditis.4 In developing countries, tuberculosis is The following data were retrieved from medi- the main cause of infectious pericarditis, and an in- cal charts: demographic data, clinical history, length cidence of 70 to 80% of the infectious pericarditis is of symptoms from onset to hospitalization, data from reported in Africa, 90% in HIV positive patients.5 In physical examination, imaging exams, ADA activity a series in South Africa, tuberculosis was the etiol- of the pericardial and pleural effusion (when pres- ogy found in 69.5% of the 233 cases submitted to ent), mycobacterium cultures from the pericardial pericardial effusion drainage.6 Among the causes of effusion or pericardial tissue, and histopathology of pericarditis in developed countries, tuberculosis ac- the pericardium. counts for about 4 to 5%.5,7 e Data supplied by Unidade de Vigilância à Saúde – Butantan, da Secretaria de Higiene e Saúde da Prefeitura Municipal de São Paulo, SP. 4 Tuberculous pericarditis : experience in a community hospital Pericardial biopsies were performed through (case 2) died due to complications related to tuber- subxiphoid approach. Histopathological slides from culous pericarditis. Autopsy confirmed tuberculosis all cases submitted to biopsy were reviewed by a in the pericardium (Figures 1 to 3), lung, pulmonary second pathologist. All histopathological slides were hilar lymph node and foci of hematogenic dissemi- stained with Hematoxilin-Eosin and Ziehl-Neelsen nation in the lungs and both adrenals with positive for AFB research. AFB in all these sites. This patient also had hepa- tosplenic schistosomiasis. The other patients were RESULTS released and followed up in the outpatient clinic. Laboratorial and some demographic data of Reported length of symptoms ranged from 6 the studied cases are summarized in Table 1. Age to 16 weeks, with an average of 9.5 weeks. Preva- ranged from 17 to 62 years. The average was 30 lence of the reported symptoms and physical ex- and the median was 25.5 years. Four (66.7%) pa- amination findings are presented in Table 2. A com- tients
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