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| {{Pericarditis}} | | {{Tuberculous pericarditis}} |
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| {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.
| | '''For patient information click, [[Pericarditis (patient information)|here]].''' |
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| ==Overview==
| | '''To go back to the main page on Pericarditis, click [[Pericarditis|here]].''' |
| The incidence of [[tuberculosis]] caused by ''[[Mycobacterium tuberculosis]]'' and its complications has significantly decreased in developed nations while it remains high in developing countries. Approximately one third of the world population is believed to be infected with [[tuberculosis]](TB)<ref name="pmid18810682">{{cite journal| author=Lönnroth K, Raviglione M| title=Global epidemiology of tuberculosis: prospects for control. | journal=Semin Respir Crit Care Med | year= 2008 | volume= 29 | issue= 5 | pages= 481-91 | pmid=18810682 | doi=10.1055/s-0028-1085700 | pmc= | url= }} </ref>. In 2006 [[WHO]] estimated the global prevalence of active [[TB]]<ref>WHO. Global Tuberculosis control. WHO/HTM/TB/2008.393. Geneva: World Health Organization; 2008. Available online at http://www.who.int/tb/publications/global_report/2008/en/index.html (Accessed June 27, 2011)</ref> to be 14.4 million cases. [[TB]] accounts for 1.7 million deaths worldwide. One of the important complications of [[TB]] is [[pericarditis]] which is the inflammation of pericardial sac that encases heart.
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| ==Epidemiology and demographics==
| | {{CMG}}; '''Associate Editors-In-Chief:''' {{Fs}}, [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. |
| Tuberculous pericarditis is found in approximately 1-2% of patients with [[pulmonary tuberculosis]]<ref name="pmid2046135">{{cite journal| author=Fowler NO| title=Tuberculous pericarditis. | journal=JAMA | year= 1991 | volume= 266 | issue= 1 | pages= 99-103 | pmid=2046135 | doi= | pmc= | url= }} </ref><ref name="pmid7377888">{{cite journal| author=Larrieu AJ, Tyers GF, Williams EH, Derrick JR| title=Recent experience with tuberculous pericarditis. | journal=Ann Thorac Surg | year= 1980 | volume= 29 | issue= 5 | pages= 464-8 | pmid=7377888 | doi= | pmc= | url= }} </ref>. It is the most common cause of pericarditis in Africa and other developing countries where TB is a major public health problem<ref>Mayosi BM, Volmink JA, Commerford PJ. Pericardial disease: an evidence-based approach to diagnosis and treatment. In: Yusuf S, Cairns JA, Camm AJ, Fallen BJ, eds. Evidence-Based Cardiology. 2nd ed. London: BMJ Books; 2003: 735–748.</ref>. The incidence is increasing rapidly in presence of [[HIV]]<ref name="pmid1967676">{{cite journal| author=Cegielski JP, Ramiya K, Lallinger GJ, Mtulia IA, Mbaga IM| title=Pericardial disease and human immunodeficiency virus in Dar es Salaam, Tanzania. | journal=Lancet | year= 1990 | volume= 335 | issue= 8683 | pages= 209-12 | pmid=1967676 | doi= | pmc= | url= }} </ref>.
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| In a study at Western Cape Province of South Africa, tuberculous pericarditis was noted in 69.5% of patients who were referred for diagnostic [[pericardiocentesis]] and one half of the patients were infected with [[HIV]]<ref name="pmid15962545">{{cite journal| author=Reuter H, Burgess LJ, Doubell AF| title=Epidemiology of pericardial effusions at a large academic hospital in South Africa. | journal=Epidemiol Infect | year= 2005 | volume= 133 | issue= 3 | pages= 393-9 | pmid=15962545 | doi= | pmc=PMC2870262 | url= }} </ref>. In contrast, the incidence of tuberculous pericarditis is 4% in developed countries<ref name="pmid3351140">{{cite journal| author=Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J| title=Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. | journal=J Am Coll Cardiol | year= 1988 | volume= 11 | issue= 4 | pages= 724-8 | pmid=3351140 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3351140 }} </ref>.
| | '''''Synonyms and keywords:''''' TB pericarditis |
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| ==Natural history and complications== | | == [[Tuberculous pericarditis overview|Overview]] == |
| Tuberculous pericarditis often has a complicated course and poor clinical outcomes. It can lead to '''[[pericardial effusion]]''' and subsequently, '''[[cardiac tamponade]]''' which may require urgent intervention including [[pericardiocentesis]]. The mortality rate of tuberculous pericarditis in the preantibiotic era was 80-90%<ref>Harvey AM, Whitehill MR. Tuberculous pericarditis. Medicine. 1937; 16: 45–94</ref>. The mortality rate in the modern era is currently 8-17%<ref name="pmid472922">{{cite journal| author=Desai HN| title=Tuberculous pericarditis. A review of 100 cases. | journal=S Afr Med J | year= 1979 | volume= 55 | issue= 22 | pages= 877-80 | pmid=472922 | doi= | pmc= | url= }} </ref><ref name="pmid7185934">{{cite journal| author=Bhan GL| title=Tuberculous pericarditis. | journal=J Infect | year= 1980 | volume= 2 | issue= 4 | pages= 360-4 | pmid=7185934 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7185934 }} </ref> and is 17-34% if the TB is associated with HIV<ref name="pmid10908256">{{cite journal| author=Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A| title=Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. | journal=Heart | year= 2000 | volume= 84 | issue= 2 | pages= 183-8 | pmid=10908256 | doi= | pmc=PMC1760932 | url= }} </ref>.
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| Tuberculous pericarditis can also cause '''[[heart failure]]''' as observed in Eastern Cape and Zimbabwe where it is a common cause, but less common than [[rheumatic heart disease]] and more common than [[hypertensive heart disease]] and [[cardiomyopathy]]<ref name="pmid6509811">{{cite journal| author=Strang JI| title=Tuberculous pericarditis in Transkei. | journal=Clin Cardiol | year= 1984 | volume= 7 | issue= 12 | pages= 667-70 | pmid=6509811 | doi= | pmc= | url= }} </ref><ref name="pmid9810393">{{cite journal| author=Hakim JG, Manyemba J| title=Cardiac disease distribution among patients referred for echocardiography in Harare, Zimbabwe. | journal=Cent Afr J Med | year= 1998 | volume= 44 | issue= 6 | pages= 140-4 | pmid=9810393 | doi= | pmc= | url= }} </ref>
| | == [[Tuberculous pericarditis historical perspective|Historical Perspective]] == |
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| '''[[Constrictive pericarditis]]''' is another complication of tuberculous pericarditis occurring in 30-60% of patients despite prompt antituberculosis treatment and the use of corticosteroids<ref name="pmid14443596">{{cite journal| author=SCHRIRE V| title=Experience with pericarditis at Groote Schuur Hospital, Cape Town: an analysis of one hundred and sixty cases studied over a six-year period. | journal=S Afr Med J | year= 1959 | volume= 33 | issue= | pages= 810-7 | pmid=14443596 | doi= | pmc= | url= }} </ref><ref name="pmid3351140">{{cite journal| author=Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J| title=Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. | journal=J Am Coll Cardiol | year= 1988 | volume= 11 | issue= 4 | pages= 724-8 | pmid=3351140 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3351140 }} </ref>
| | == [[Tuberculous pericarditis classification|Classification]] == |
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| ==Pathophysiology== | | == [[Tuberculous pericarditis pathophysiology|Pathophysiology]] == |
| Tuberculous pericarditis develops as a result of lymphatic spread from peritracheal, peribronchial or [[mediastinal lymphnodes]] or by contiguous spread from a focus of infection in lung or pleura. This causes acute inflammation of the pericardium with infiltration of polymorphonuclear (PMN) leukocytes and pericardial vascularization. This may lead to [[pericardial effusion]] and fibrinous change of pericardium. There are four pathologic stages of involvement:<ref name="pmid18610109">{{cite journal| author=Peel AA| title=TUBERCULOUS PERICARDITIS. | journal=Br Heart J | year= 1948 | volume= 10 | issue= 3 | pages= 195-207 | pmid=18610109 | doi= | pmc=PMC481044 | url= }} </ref><ref name="pmid4050698">{{cite journal| author=Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J| title=Primary acute pericardial disease: a prospective series of 231 consecutive patients. | journal=Am J Cardiol | year= 1985 | volume= 56 | issue= 10 | pages= 623-30 | pmid=4050698 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050698 }} </ref><ref name="pmid16330703">{{cite journal| author=Mayosi BM, Burgess LJ, Doubell AF| title=Tuberculous pericarditis. | journal=Circulation | year= 2005 | volume= 112 | issue= 23 | pages= 3608-16 | pmid=16330703 | doi=10.1161/CIRCULATIONAHA.105.543066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16330703 }} </ref>
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| :'''Stage 1:''' Presence of diffuse fibrin deposition, granulomas and abundant mycobacterium
| | == [[Tuberculous pericarditis causes|Causes]] == |
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| :'''Stage 2:''' Development of serous or serosanguineous pericardial effusion with a predominantly lymphocytic exudate with monocytes and foam cells
| | == [[Pericarditis differential diagnosis|Differentiating Tuberculous Pericarditis from other Diseases]] == |
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| :'''Stage 3:''' Absorption of effusion with organization of granulomatous caseation and thickening of pericardium secondary to deposition of fibrin and collagen.
| | == [[Tuberculous pericarditis epidemiology and demographics|Epidemiology and Demographics]] == |
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| :'''Stage 4:''' Development of [[constrictive pericarditis]]. Pericardial space is obliterated by dense adhesions with marked thickening of parietal layer and replacement of [[granulomas]] by fibrous tissue.
| | == [[Tuberculous pericarditis risk factors|Risk Factors]] == |
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| Effusive constrictive pericarditis<ref name="pmid14749455">{{cite journal| author=Sagristà-Sauleda J, Angel J, Sánchez A, Permanyer-Miralda G, Soler-Soler J| title=Effusive-constrictive pericarditis. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 5 | pages= 469-75 | pmid=14749455 | doi=10.1056/NEJMoa035630 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14749455 }} </ref> may be seen in some patients. The visceral pericardium thickens with fibrin deposition (changes of [[constrictive pericarditis]]) and concomitantly there is presence of pericardial effusion which may present as [[cardiac tamponade]]. In this scenario, the [[diastolic pressure]] continues to be elevated after pericardiocentesis due to persistent constriction.
| | == [[Tuberculous pericarditis screening|Screening]] == |
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| | == [[Tuberculous pericarditis natural history|Natural History, Complications and Prognosis]] == |
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| ==Diagnosis== | | ==Diagnosis== |
| Tuberculous pericarditis has a variable clinical presentation and should be considered in the evaluation of all cases of pericarditis that are not self-limiting<ref name="pmid3351140">{{cite journal| author=Sagristà-Sauleda J, Permanyer-Miralda G, Soler-Soler J| title=Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. | journal=J Am Coll Cardiol | year= 1988 | volume= 11 | issue= 4 | pages= 724-8 | pmid=3351140 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3351140 }} </ref>. | | [[Tuberculous pericarditis diagnostic study of choice|Diagnostic study of choice]] | [[Tuberculous pericarditis history and symptoms|History and Symptoms]] | [[Tuberculous pericarditis physical examination|Physical Examination]] | [[Tuberculous pericarditis laboratory findings|Laboratory Findings]] | [[Tuberculous pericarditis electrocardiogram|Electrocardiogram]] | [[Tuberculous pericarditis x ray|X-Ray Findings]] | [[Tuberculous pericarditis echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Tuberculous pericarditis CT scan|CT-Scan Findings]] | [[Tuberculous pericarditis MRI|MRI Findings]] | [[Tuberculous pericarditis other imaging findings|Other Imaging Findings]] | [[Tuberculous pericarditis other diagnostic studies|Other Diagnostic Studies]] |
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| ===History and symptoms=== | | ==Treatment== |
| The patients present with following symptoms:
| | [[Tuberculous pericarditis medical therapy|Medical Therapy]] | [[Tuberculous pericarditis interventions|Interventions]] | [[Tuberculous pericarditis surgery|Surgery]] | [[Tuberculous pericarditis primary prevention|Primary Prevention]] | [[Tuberculous pericarditis secondary prevention|Secondary Prevention]] | [[Tuberculous pericarditis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Tuberculous pericarditis future or investigational therapies|Future or Investigational Therapies]] |
| *[[Fever]]
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| *[[Weight loss]]
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| *[[Night sweats]]
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| *[[Cough]]
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| *[[breathlessness]]
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| *[[Chest pain]] which changes with posture
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| *[[Malaise]]
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| *Ankle [[edema]]
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| Frequency and severity of above symptoms varies with stage of infection, the degree of involvement of [[pericardium]], and the degree of extrapericardial infection.
| | ==Related Chapters== |
| | * [[Pericarditis]] |
| | * [[Tuberculosis]] |
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| ===Physical examination===
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| Patients present with [[fever]] and [[cachexia]].
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| '''Vitals:''' [[Tachycardia]], [[pulsus paradoxus]] and hypotension(in [[cardiac tamponade]])
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| '''Neck:''' [[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]]
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| '''Chest:''' Pleural dullness, decreased breath sounds, pericardial knock, [[pericardial rub]] and distant [[heart sounds]]
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| '''Abdomen:''' [[Hepatomegaly]], [[ascites]]
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| '''Extremities:''' [[Ankle edema]]
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| ===Chest X-ray===
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| Pulmonary infiltration by the bacterium may be seen in approximately 32%<ref name="pmid4593515">{{cite journal| author=Fowler NO, Manitsas GT| title=Infectious pericarditis. | journal=Prog Cardiovasc Dis | year= 1973 | volume= 16 | issue= 3 | pages= 323-36 | pmid=4593515 | doi= | pmc= | url= }} </ref>, [[pleural effusion]] in 40% to 60%, and [[cardiomegaly]] in about 90% of patients with tuberculous pericarditis<ref name="pmid15915278">{{cite journal| author=Reuter H, Burgess LJ, Doubell AF| title=Role of chest radiography in diagnosing patients with tuberculous pericarditis. | journal=Cardiovasc J S Afr | year= 2005 | volume= 16 | issue= 2 | pages= 108-11 | pmid=15915278 | doi= | pmc= | url= }} </ref><ref name="pmid5410398">{{cite journal| author=Rooney JJ, Crocco JA, Lyons HA| title=Tuberculous pericarditis. | journal=Ann Intern Med | year= 1970 | volume= 72 | issue= 1 | pages= 73-81 | pmid=5410398 | doi= | pmc= | url= }} </ref>.
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| [http://www.radiopaedia.org Image shown below is courtesy of Radiopedia]
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| [[Image:Tuberculous pericarditis.jpg|thumb|350px|left|14 year old child with tubercular pleural and pericardial effusion. Decortication was performed on left side. Pericardial effusion was aspirated with a wide bore needle on 3 occasions, it reaccumulated immediately.]]
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| ===Electrocardiogram===
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| [[ECG]] may show non-specific ST-T–wave changes<ref name="pmid14443596">{{cite journal| author=SCHRIRE V| title=Experience with pericarditis at Groote Schuur Hospital, Cape Town: an analysis of one hundred and sixty cases studied over a six-year period. | journal=S Afr Med J | year= 1959 | volume= 33 | issue= | pages= 810-7 | pmid=14443596 | doi= | pmc= | url= }} </ref><ref name="pmid11447490">{{cite journal| author=Smedema JP, Katjitae I, Reuter H, Burgess L, Louw V, Pretorius M et al.| title=Twelve-lead electrocardiography in tuberculous pericarditis. | journal=Cardiovasc J S Afr | year= 2001 | volume= 12 | issue= 1 | pages= 31-4 | pmid=11447490 | doi= | pmc= | url= }} </ref>. Characteristic EKG finding of acute pericarditis, PR-segment deviation and diffuse ST-segment elevation are found in only 9-11% of cases<ref name="pmid5410398">{{cite journal| author=Rooney JJ, Crocco JA, Lyons HA| title=Tuberculous pericarditis. | journal=Ann Intern Med | year= 1970 | volume= 72 | issue= 1 | pages= 73-81 | pmid=5410398 | doi= | pmc= | url= }} </ref><ref name="pmid11447490">{{cite journal| author=Smedema JP, Katjitae I, Reuter H, Burgess L, Louw V, Pretorius M et al.| title=Twelve-lead electrocardiography in tuberculous pericarditis. | journal=Cardiovasc J S Afr | year= 2001 | volume= 12 | issue= 1 | pages= 31-4 | pmid=11447490 | doi= | pmc= | url= }} </ref>. Presence of micro-voltage and [[electrical alternans]] suggests pericardial effusion and tamponade.
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| [[Image:12leadpericarditis.png|thumb|500px|left|ECG in acute pericarditis showing diffuse ST elevation]][[Image:PulsusAlternans.jpg|thumb|500px|center|Electrical alternans]]
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| ===Echocardiography===
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| Echocardiographic findings in '''[[constrictive pericarditis]]''' include thickened [[pericardium]] with dilated [[atria]] and [[venae cavae]]. In '''[[pericardial effusion]]''', large hypoechoic regions are seen surrounding the heart with presence of oscillatory motion of heart. '''[[Cardiac tamponade]]''' demonstrates right atrial collapse, right ventricular diastolic collapse, and increased variation of mitral and tricuspid flow with respiration.
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| '''Below is a video demonstrating echocardiographic features of cardiac tamponade'''
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| <youtube v=YWVI6rRTIzU/>
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| ===MRI===
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| Below is a video demonstrating MR findings of constrictive pericarditis where, in mid-diastole, the thickened pericardium begins to restrict right ventricular filling, causing a rapid increase in ventricular pressure. Early changes of septal flattening and bowing of the interventricular septum toward the left ventricle (normally concave in shape toward the left ventricle during diastolic filling) are seen. This pressure change results in diastolic septal dysfunction, the septal bounce described in echocardiography.
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| <youtube v=5srXVJdWIAM/>
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| ===Cardiac catheterization===
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| *'''Cardiac tamponade:''' Pressures in all four chambers of heart are in equilibrium.
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| *'''Constrictive pericarditis:''' Equalization of elevated right atrial and pulmonary artery wedge pressures may be noted with a diastolic dip and plateau in the right ventricular tracing.
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| *'''Effusive constrictive pericarditis:''' Cardiac tamponade findings are noted initially. Findings of constrictive pericarditis are unmasked following [[pericardiocentesis]].
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| ==References==
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| {{reflist|2}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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| [[Category:Inflammations]] | | [[Category:Inflammations]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Infectious disease]]
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| {{WH}}
| | [[Category:Tuberculosis]] |
| {{WS}}
| | [[Category:Disease]] |