Tuberculous Pericarditis Presenting As Multiple Free Floating Masses in Pericardial Effusion
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CASE REPORT Pediatrics http://dx.doi.org/10.3346/jkms.2012.27.3.325 • J Korean Med Sci 2012; 27: 325-328 Tuberculous Pericarditis Presenting as Multiple Free Floating Masses in Pericardial Effusion Shin-Ae Yoon1, Youn-Soo Hahn1, Pericarditis is a rare manifestation of tuberculosis (Tb) in children. A 14-yr-old Korean boy Jong Myeon Hong2, Ok-Jun Lee3, presented with cardiac tamponade during treatment of pulmonary tuberculosis. He and Heon-Seok Han1 developed worsening anemia and persistent fever in spite of anti-tuberculosis medications. Echocardiography found free floating multiple discoid masses in the pericardial effusion. Departments of 1Pediatrics, 2 Thoracic and Cardiovascular Surgery, and 3Pathology, Chungbuk The masses and exudates were removed by pericardiostomy. The masses were composed of National University Hospital, Chungbuk National pink, amorphous meshwork of threads admixed with degenerated red blood cells and University College of Medicine, Cheongju, Korea leukocytes with numerous acid-fast bacilli, which were confirmed asMycobacterium species by polymerase chain reaction. The persistent fever and anemia were controlled Received: 30 May 2011 Accepted: 4 November 2011 after pericardiostomy. This is the report of a unique manifestation of Tb pericarditis as free floating masses in the effusion with impending tamponade. Address for Correspondence: Heon-Seok Han, MD Key Words: Pericarditis; Tuberculosis; Pericardial Effusion; Cardiac Tamponade Department of Pediatrics, Chungbuk National University College of Medicine, 52 Naesudong-ro, Heungdeok-gu, Cheongju 361-711, Korea Tel: +82.43-269-6370, Fax: +82.43-264-6620 E-mail: [email protected] INTRODUCTION received BCG at 4 weeks of age. Tuberculosis (Tb) was absent in the family history. On physical examination, he was alert and Tuberculosis (Tb) is responsible for approximately 4% of cases well-nourished. His vital sign was as follows; temperature 38oC, of acute pericarditis, 7% of cases of cardiac tamponade, and, in heart rate 126/min, and respiration rate 24/min. Chest exam older studies 6% of instances of constrictive pericarditis. How- revealed coarse breath sound and wheezing. Tuberculin puri- ever, in some non-industrialized countries, tuberculosis is a lead- fied protein derivative skin test was negative, but sputum showed ing cause of pericarditis (1). Tuberculous pericarditis presents positive for acid fast bacilli (AFB). Chest radiograph on admis- clinically 3 forms, namely, pericardial effusion, constrictive peri- sion revealed haziness in right upper and middle lung field (Fig. carditis, and a combination of effusion and constriction (2). 1A), and high resolution chest computerized tomography showed Echocardiography is very useful for the diagnosis of tubercu- consolidation, micronodules and branching structures in right lous pericardial effusion if the intrapericardial abnormalities, lung and lymph node (LN) enlargement in both hilum with peri- including exudative coating, fibrinous strands, and thickened cardial effusion (Fig. 1B). He was managed as pulmonary Tb pericardium are present (3). We experienced very unusual case with isoniazid, rifampicin, pyrazinamide and ethambutol. The of Tb pericarditis presenting as free floating multiple echogenic AFB was identified as M. tuberculosis and was sensitive to all masses in the pericardial effusion with impending tamponade. the Tb medications except isoniazid in the culture study. Pre- The masses were proved to be blood clot with numerous acid- dinisolone was given for total 2 months with tapering. In spite fast bacilli. of Tb medication, he complained persisting fever, aggravating cough and chest pain. Chest exam revealed decreased breath CASE DESCRIPTION sound and chest radiograph revealed aggravated haziness in the right lung with newly appeared consolidation in right lower lung On 15 August 2010, a 14-yr old boy was transferred to our hos- field with a pattern of pericardial effusion (Fig. 1C) on the 7th pital for uncontrolled pneumonia. He developed cough, spu- day. In the mean while, his hemoglobin decreased gradually from tum and malaise 16 days ago, and he had been managed with 11.3 g/dL to 9.6 g/dL, but C-reactive protein (CRP) initially in- antibiotics, but his symptoms were aggravated clinically and ra- creased from 14.5 mg/dL to 25.4 mg/dL on the 3rd hospital day, diographically. He also showed night sweat and fever, but weight and then decreased to 7.6 mg/dL on the 9th day (Fig. 2). Echo- loss was absent. He had been healthy until the recent illness. He cardiography showed free floating multiple round discoid mass- © 2012 The Korean Academy of Medical Sciences. pISSN 1011-8934 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 1598-6357 Yoon S-A, et al. • Multiple Floating Masses in Tuberculous Pericarditis es in large amount of pericardial effusion (Fig. 3A) and marked 13 Hb CRP 30 variation in mitral inflow Doppler with respiration suggesting 25 impending tamponade (Fig. 3B). On the 9th day, pericardial effu- 12 pericardiostomy sion and the discoid masses were removed by pericardiostomy. 20 Pericardial fluid was pinkish and AFB (+). The yellowish discoid 11 masses were soft and fragile (Fig. 4). Microscopic exam revealed 15 that the masses were composed of pink, amorphous meshwork Hb (g/dL) Hb 10 of threads admixed with degenerated red blood cells and leu- 10 (mg/dL) CRP kocytes (Fig. 5A) with numerous acid-fast bacilli (Fig. 5B). After 9 pericardiostomy the fever came down and hemoglobin rose up 50 to 11.9 g/dL and CRP came down to 0.84 mg/dL on the 30th day (Fig. 2). He is still taking anti-Tb medication with marked improve- 8 0 HD 1 HD 3 HD 9 HD 11 HD 16 ment of chest radiogram. We performed real time polymerase chain reaction (PCR, LG Life Science, Seoul, Korea) for Myco- Fig. 2. Hemoglobin (Hb) was decreased gradually since admission till the 9th hospital bacterium tuberculosis using paraffin-embedded tissue, and day (HD), when pericardiostomy was performed. C-reactive protein (CRP) increased initially and then decreased. After pericardiostomy, hemoglobin increased till discharge confirmed that AFB wereMycobacterium species. and CRP also decreased to normal at discharge. A B C Fig. 1. Radiologic findings of the chest. A( ) Haziness in right upper and middle lung was noted. (B) Consolidation, micronodules, and branching structures were found in the right lung, and lymph node enlargements were noted in both hilum. (C) Aggravated haziness in the right lung and newly appeared consolidation in the right lower lung were found on 7th hospital day. A B Fig. 3. Echocardiographic findings. (A) Free floating multiple round discoid echogenic masses in the large amount of pericardial effusion, the thickened pericardium and shaggy echo-dense appearance surrounding the epicardium in subcostal view, and (B) marked variation in mitral inflow Doppler pattern. 326 http://jkms.org http://dx.doi.org/10.3346/jkms.2012.27.3.325 Yoon S-A, et al. • Multiple Floating Masses in Tuberculous Pericarditis DISCUSSION raphy showed a solid mass that originated from the thickened pericardium and compressed the whole heart. The symptoms It is very peculiar that Tb pericarditis manifested as multiple and signs dramatically improved after surgical pericardiectomy free-floating pericardial masses in the effusion with impending (4). Another similar African case was reported in 16-yr-old boy, tamponade. How could the discoid masses be made in the mid- who was hospitalized for fever, chest pain, and cardiovascular dle of pericardial fluid? We assumed as follows. With great in- collapse. Echocardiography revealed a 30-mm circumferential crease in permeability due to Tb pericarditis, hemorrhage and echogenic “porridge-like” pericardial effusion with signs of car- fibrinous exudates developed in pericardial fluid. Red blood cells diac tamponade. The effusion and fibrinous pockets were re- and fibrinous and proteinous materials came into collision with moved by subxiphoid pericardiotomy (5). The porridge-like peri- each other, and they became conglomerated and bigger in size, cardial effusion was echogenic and associated with fibrinous and consequently discrete masses were formed in the pericar- strands. The effusion in African case might be changing to solid dial effusion. This phenomenon might be accelerated by cardiac mass similar to Taiwan and our cases. movement. With the compressive force in between the visceral Pericardial involvement usually develops by retrograde lym- and parietal pericardium, the masses became discoid shape. phatic spread of M. tuberculosis from peritracheal, peribronchi- In the literature search, we found at least two similar but dif- al, or mediastinal lymph node or by hematogenous spread from ferent pediatric cases of Tb pericarditis in Taiwan and Africa. Lin primary tuberculous infection (2). Pathologically, Tb pericardi- et al. (4) reported a 10-month-old girl with fibrinofibrous pericar- tis is recognized as four stages: 1) fibrinous exudation with ini- ditis that manifested as constrictive pericarditis with prolonged tial polymorphonuclear leukocytosis, relatively abundant my- fever, hepatomegaly, edema, and poor appetite. Echocardiog- cobacteria, and early granuloma formation with loose organiza- tion of macrophage and T cells; 2)