Biventricular Heart Failure Secondary to Calcified Tuberculous Constrictive Pericarditis: a Case Report and Review

Revista Mexicana de Cardiología C C B R Vol. 27 No. 2 April-June 2016 Biventricular heart failure secondary to calcified tuberculous constrictive pericarditis: a case report and review Falla cardiaca biventricular secundaria a pericarditis constrictiva calcificada de origen tuberculoso: reporte de un caso y revisión Víctor Hugo Contreras-Gutiérrez* Key words: Pulmonary ABSTRACT RESUMEN tuberculosis, heart failure, calcifi ed A 41-year-old man with a medical history of pulmonary Un hombre de 41 años con antecedente de tuberculosis pericardium. tuberculosis presented to the emergency department com- pulmonar se presentó en el servicio de urgencias refi rien- plaining of progressive dyspnea, lower limbs edema and do un cuadro de disnea progresiva, edema de miembros Palabras clave: increased abdominal volume of three months of evolution. inferiores e incremento del volumen abdominal de tres Tuberculosis He was diagnosed of heart failure by clinical fi ndings. meses de evolución. El paciente fue diagnosticado de pulmonar, However imaging tests showed a heavily thickened cal- insufi ciencia cardiaca por los hallazgos clínicos. Sin insufi ciencia cifi ed pericardium and bilateral pleural eff usion. A skin embargo estudios de imagen mostraron un pericardio cardiaca, pericardio tuberculin test was performed, giving a positive result. importantemente calcifi cado y derrame pleural bilateral. calcifi cado. The diagnosis of biventricular heart failure secondary to Se realizó la prueba de tuberculina, siendo positiva. Se lle- calcifi ed tuberculous pericarditis was reached. The patient gó al diagnóstico de insufi ciencia cardiaca biventricular rejected surgical intervention and conservative treatment secundaria a pericarditis constrictiva de origen tubercu- for heart failure as per guidelines was implemented. loso. El paciente rechazó la intervención quirúrgica y se implementó tratamiento conservador para falla cardiaca sustentado en guías. INTRODUCTION pericarditis and neoplastic pericardial diseases and high (20-30%) in bacterial pericarditis, onstrictive pericarditis is the result of a especially purulent pericarditis.3 Cchronic inflammatory process that leads to In constrictive pericarditis the diastolic fill- scarring, thickening, fibrosis and calcification ing of the ventricles is impaired and clinical of the pericardium which leads to impaired manifestations are generally those of right heart diastolic filling of the heart. The most common failure with preserved left ventricular func- causes are mediastinal radiation, chronic idio- tion, at least in the first stages of the disease. pathic pericarditis, and after cardiac surgery in Symptoms include fatigue, peripheral edema, developedwww.medigraphic.org.mx countries. However, tuberculosis is breathlessness, passive hepatic congestion, * Medical Resident at still the most frequent cause in the developing nonspecific abdominal complaints; and as the the General Hospital of and underdeveloped world, as well as, in im- disease progresses, abdominal swelling second- Mexico. munocompromised patients.1,2 It can occur af- ary to ascites, jaundice, generalized edema and ter virtually any pericardial disease process but cardiac cirrhosis. Other important signs are the Received: 09/05/2016 the risk of progression is related to the etiology; recurrent pleural effusions and syncope, due Accepted: being low (1%) in viral and idiopathic pericar- to low output status secondary to reduced 11/07/2016 ditis, intermediate (2-5%) in immune-mediated preload.3-7 Rev Mex Cardiol 2016; 27 (2): 95-100 www.medigraphic.com/revmexcardiol 96 Contreras-Gutiérrez VH. Biventricular heart failure secondary to calcifi ed tuberculous constrictive pericarditis The jugular veins are distended. The normal bpm and right bundle branch block with a QRS inspiratory drop in jugular venous distention axis to 90o without any other alteration. Chest may be replaced by a rise in venous pressure X-ray showed right pleural effusion and signs (Kussmaul’s sign) due to a right ventricle unable of congestive heart failure with an enlarged to accommodate the blood proceeding from cardiac silhouette, redistribution and interstitial the venous return, being into a fixed space, edema. It was observed an area of increased delimited by the stiff pericardium. Kussmaul’s density suggestive of a calcified pericardium sign is also present in cases of severe right heart (Figure 1). failure, especially in association with tricuspid Echo imaging reported dilated right heart regurgitation. Pulsus paradoxus is present cavities with paradoxical septum motion, re- when systolic pressure decreases more than duced right ventricular systolic function with 10 mmHg during inspiration, and it is second- a tricuspid annulus plane systolic excursion ary to the shift of the interventricular septum (TAPSE) of 13 mm (normal > 17), elevated to the left, impeding an adequate filling of the systolic pulmonary artery pressure (SPAP) of left ventricle. The classic auscultatory finding of 65 mmHg, mild tricuspid regurgitation and pericardial constriction is a pericardial knock a restrictive diastolic filling pattern, with an that occurs as a high-pitched sound early in E/A index of 2.4. The pericardium layers were diastole when there is the sudden cessation hyperechoic. of rapid ventricular diastolic filling. When ac- A computed tomography (CT) scan was curately recognized, a pericardial knock is a performed to obtain a better visualization of specific but insensitive indicator of pericardial the pericardium. It showed a thick and heavily constriction.1-7 calcified pericardium affecting the most part of In many cases of chronic pericardial con- the cardiac circumference. A moderate right striction, definitive treatment is surgical and pleural effusion, as documented previously consists in wide resection of both pericardial on chest X-ray, was still present (Figure 2 A-C). layers, however it has a high mortality risk that Extension of the CT scanning to the abdomen, goes from 6 to 12% according to different case showed hepatic and splenic enlargement, ac- series.1,3-9 companied by moderate ascites (Figure 3). On his medical history, he referred having CLINICAL CASE been diagnosed of pulmonary tuberculosis A 41-year-old man with a medical history of pulmonary tuberculosis presented to the emergency department complaining of dyspnea, lower limbs edema and increased abdominal volume of 3 months of evolution. This occasion with exacerbation of symptoms. On first examination, elevated jugular venous pressure was evident, with an estimated pressure of 11 cmH2O; rales at the base of both lungs were auscultated, with decreased respira- tory sounds at the base of the right lung; generalized edema was present, mainly affecting the lowerwww.medigraphic.org.mx limbs; first and second heart sounds were diminished in intensity, and a prominent third heart sound (a pericardial knock) in early diastole was present. The patient was admitted to hospitalization for hemodynamic stabiliza- Figure 1. Chest X-ray showing signs of congestive heart tion and further research. failure with right pleural eff usion, an enlarged cardiac It was documented on electrocardiogram silhouette, and an image of increased density (arrows) (ECG) the presence of sinus tachycardia of 130 suggestive of pericardial calcium. Rev Mex Cardiol 2016; 27 (2): 95-100 www.medigraphic.com/revmexcardiol Contreras-Gutiérrez VH. Biventricular heart failure secondary to calcifi ed tuberculous constrictive pericarditis 97 Figure 2 A-C. Thoracic CT imaging at diff erent axial segments showing a thickened calcifi ed pericardium and moderate right pleural eff usion. of pericardial effusion cases in human immu- nodeficiency virus (HIV) infected people, and for 50-70% in developing countries where tuberculosis is endemic. Congestive heart failure secondary to chronic compression is the most common clinical presentation. Mortality in these patients is high, ranging from 17-40% at six months after diagnosis.3 In the world extra-pulmonary tuberculosis represents 10% of cases. Tuberculous pericarditis, caused by Mycobacterium tuberculosis, is found in approximately 1% of all autopsied cases of tuberculosis and in 1% to 2% of in- Figure 3. Abdominal CT showing hepatic and splenic stances of the pulmonary form of the disease. enlargement accompanied by ascites. The incidence of the disease is highly variable depending on regional aspects, in Latin America it goes from 0.5% to 1.5% and till 2007 showing three years ago and that he interrupted treat- an annual decrease of approximately 5%.10 In ment voluntarily at the third month of initia- 2009 in Mexico 17.5% of tuberculosis cases tion with no subsequent following up. A skin were extra-pulmonary.11 tuberculin test was performed, being positive. In México it has been observed an as- Calcified tuberculous constrictive pericardi- sociation between tuberculosis and diabetes tis was diagnosed and first-line antitubercular mellitus, malnutrition, and alcohol and drugs agents were initiated. Surgical treatment (peri- consumption. Overcrowding and a low cultural cardiectomy) was proposed to the patient, level are also risk factors to have the disease.12 explaining the benefits and risks of the pro- Pericardial involvement usually develops by cedure. He refused surgical intervention, and retrograde lymphatic spread of M. tuberculosis pharmacological therapy for heart failure as per from peritracheal, peribronchial, or mediastinal guidelines was implemented. lymph nodes or by hematogenous spread

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