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A Clinical Case of Tuberculosis with Transient Constrictive Pericarditis and Perimyocarditis

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A Clinical Case of Tuberculosis with Transient Constrictive Pericarditis and Perimyocarditis ID: 19-0019 -19-0019 6 3 V D Mathiasen et al. Constrictive pericarditis in 6:3 K7–K12 tuberculosis CASE REPORT A clinical case of tuberculosis with transient constrictive pericarditis and perimyocarditis V D Mathiasen BSc1,2, C A Frederiksen MD PhD3, C Wejse MD PhD1,4 and S H Poulsen MD PhD DMSc3 1Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark 2International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Kobenhavn, Denmark 3Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark 4Center for Global Health, Aarhus University, Aarhus, Denmark Correspondence should be addressed to C A Frederiksen: [email protected] Summary Tuberculous pericarditis is a rare diagnosis seen among as few as 1% of tuberculosis (TB) Key Words patients in developed countries. We present a case of a 60-year-old male suffering from f tuberculosis a transient constrictive pericarditis and subclinical involvement of the myocardium in a f perimyocarditis clinical case of tuberculous pericarditis with corresponding improvement after the initiation f constrictive pericarditis of anti-tuberculous treatment. We suggest monitoring of myocardial function using f echocardiography global longitudinal strain by myocardial speckle tracking strain analysis as supplement to f global longitudinal strain routine left ventricular ejection fraction to assess clinical improvement in patients at risk of developing constrictive pericarditis. Learning points: • Tuberculous pericarditis is rare and a diagnostic challenge in low-incidence countries. • Patients with tuberculosis and involvement of the heart are at high risk of developing constrictive pericarditis. • Novel imaging techniques, such as estimation of global longitudinal strain using myocardial speckle tracking analysis, may be useful in assessing cardiac involvement in tuberculosis patients. Background Case presentation Tuberculous pericarditis is a rare diagnosis seen among A 60-year-old male presented with coughing and as few as 1% of tuberculosis (TB) patients in developed yellowish, blood-tinged sputum, chest pain, activity- countries (1). The disease presents within the spectrum of related dyspnea (NYHA class II), night sweats, chills, acute pericarditis with or without larger effusions including diffuse joint pain and an unintended weight loss of cardiac tamponade and with subsequent development of approximately 5 kg during the last 2 months. The patient chronic constrictive pericarditis (2). In Africa, Asia and had a history of 30 years in relief work with stationing other TB high-incidence regions, it is among the most in several TB high-incidence locations and a history of common etiologies of pericarditis, constrictive disease Bacillus Calmette-Guérin immunization and a previously and heart failure (3). The pericardial involvement in this negative Mantoux test. condition is associated with a significant morbidity and Physical examination upon admission was without mortality although the disease is potentially curable (4). any abnormal cardiopulmonary findings. https://erp.bioscientifica.com © 2019 The authors This work is licensed under a Creative Commons https://doi.org/10.1530/ERP-19-0019 Published by Bioscientifica Ltd Attribution-NonCommercial-NoDerivatives 4.0 International License. Downloaded from Bioscientifica.com at 09/25/2021 05:30:24PM via free access V D Mathiasen et al. Constrictive pericarditis in 6:3 K8 tuberculosis Biochemistry showed elevated C-reactive protein microscopy, PCR and culturing, was not able to establish 120.7 (mg/L), leucocytosis 12.2 (109/L), thrombocytosis a definitive diagnosis. Nevertheless, an interferon-gamma 534 (109/L), hemoglobin 9.0 (mmol/L), and low release assay was positive. Pathological examination of albumin 26 (g/L). biopsies, obtained during thoracoscopy, revealed sparse Extensive and repeated blood sampling and chronic inflammation in the pericardial tissue. However, microbiological testing, including 19 samples sent for TB biopsies were obtained after TB treatment was commenced. Figure 1 Upper panel: electrocardiography (ECG) during the initial phase of treatment when the patients had clinical symptoms and suspicion of myocardial involvement. Significant T-wave abnormalities may be observed in I, II, aVR, aVF and V3-V6. Lower panel: ECG after complete treatment. T-wave abnormalities have been resolved. https://erp.bioscientifica.com © 2019 The authors This work is licensed under a Creative Commons https://doi.org/10.1530/ERP-19-0019 Published by Bioscientifica Ltd Attribution-NonCommercial-NoDerivatives 4.0 International License. Downloaded from Bioscientifica.com at 09/25/2021 05:30:24PM via free access V D Mathiasen et al. Constrictive pericarditis in 6:3 K9 tuberculosis The patient was treated for 6 months with Echocardiography isoniazid and rifampin and 3 months with ethambutol, A Vivid E95TM (GE Healthcare) ultrasound system and pyrazinamide, and adjuvant prednisolone and equipped with a M5Sc phased array transducer was used pyridoxine throughout the period, based on clinical for all examinations. suspicion of tuberculous pericarditis. Seven weeks after the initial evaluation, the patient deteriorated with increased dyspnea (NYHA class III), decreasing saturation and CT progression of Investigation the pericardial effusion. TTE revealed thickening of the visceral pericardium, ventricular septal bounce, a 29% Initial evaluations increase in early mitral inflow velocity during expiration, Chest X-ray displayed left-sided pleural effusions hepatic vein diastolic reversal ratio of 0.89, medial e′ and subsegmental atelectasis contralaterally, while velocity of 11.7 cm/s and a medial e′/lateral e′ ratio of 1.5 computed tomography (CT) revealed a right-sided (Fig. 3). The relationship between the medial and lateral e′ upper lobe infiltrate, and also bilateral pleural velocities represents a reversal of the typical pattern, this effusions, a pericardial effusion and enlarged mediastinal is termed ‘annulus reversus’ (5). All these signs are highly lymph nodes. indicative of constrictive pericarditis. The first electrocardiography (ECG) showed sinus Normal coronary arteries were demonstrated by rhythm and no abnormalities. However, during the coronary angiography, and simultaneous left and right initial clinical course significant T-wave abnormalities heart catherization revealed no signs of constrictive developed in I, II, aVR, aVF and V3-V6. These changes physiology including normal atrial and ventricular resolved completely at the end of treatment (Fig. 1). diastolic pressures. These examinations were however The initial transthoracic echocardiography (TTE) performed relatively late (week 10) in the clinical course, revealed left-sided pleural fluid accumulation, a when the patient had improved clinically. modest pericardial effusion and no suggestion of In addition, the pericardial involvement was assessed constrictive physiology. with serial TTEs (Fig. 4). Positron emission tomography (PET) showed Initially, TTEs showed signs of pericardial enhanced metabolic activity in the pericardium, involvement with effusion and transient constrictive indicative of active inflammation and supportive of the physiology. Interestingly, even though left ventricular presumed diagnosis (Fig. 2). FDG uptake in the adjacent ejection fraction (LVEF) were within the normal myocardium is uncertain. range at all times, we observed reduced regional and Figure 2 (A) Maximum intensity projection (MIP) image of the patient. Black arrows mark the discretely increased pericardial uptake. Gray arrows mark reactive lymph nodes. (B) Transaxial 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) of the cardiac region. Discrete pericardial 18F-FDG uptake is noted with the highest intensity (SUVmax 3.1) in the thickened parts of the pericardium. (C) Fused axial 18F-FDG PET/CT. (D) Contrast-enhanced CT performed 14 days prior to the PET/CT. Sparse pericardial fluid and thickening as well as some pleural effusion is present. https://erp.bioscientifica.com © 2019 The authors This work is licensed under a Creative Commons https://doi.org/10.1530/ERP-19-0019 Published by Bioscientifica Ltd Attribution-NonCommercial-NoDerivatives 4.0 International License. Downloaded from Bioscientifica.com at 09/25/2021 05:30:24PM via free access V D Mathiasen et al. Constrictive pericarditis in 6:3 K10 tuberculosis global longitudinal strain (GLS) corresponding to the normalization of the ECG and myocardial longitudinal affected pericardial areas visualized on TTE (Fig. 4). deformation regionally as well as globally. Gradually, and along with anti-tuberculous treatment, the pericardial involvement decreased and only limited persistent calcifications were noted. Furthermore, Discussion regional and global myocardial deformation completely Pericarditis is an important disease manifestation of returned to normal values. TB, and myocardial involvement and hemodynamic status should always be meticulously evaluated in these Treatment and outcome patients to detect potential perimyocarditis or constrictive pericarditis (6). The patient was followed regularly and continued to In developed countries, most cases of acute respond to the anti-tuberculous treatment with clinical pericarditis are due to viral infections whereas TB is a improvement. After 4–5 months, the pericardial effusion very rare etiology of acute pericarditis. Complications are and thickening had resolved completely. Yet, the ECG infrequent in acute pericarditis,
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