Tuberculous pericarditis summary

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Approach to patients with suspected tuberculous pericarditis

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Initial evaluation Chest radiograph may reveal changes suggestive of pulmonary tuberculosis in 30% of cases. Echocardiogram: the presence of a large pericardial effusion with frond-like projections, and thick "porridge-like" exudate is suggestive of an exudate but not specific for a tuberculous etiology. CT scan and/or MRI of the chest are alternative imaging modalities where available: for evidence of pericardial effusion and thickening (>5 mm) and typical mediastinal and tracheobronchial lymphadenopathy (>10 mm, hypodense centers, matting), with sparing of hilar lymph nodes. Culture of sputum, gastric aspirate, and/or urine should be considered in all patients. Right scalene lymph node biopsy if pericardial fluid is not accessible and lymphadenopathy is present. Tuberculin skin test is not helpful regardless of the background prevalence of tuberculosis.5,50 Pericardiocentesis Therapeutic pericardiocentesis is indicated in the presence of cardiac tamponade. Diagnostic pericardiocentesis should be considered in all patients with suspected tuberculous pericarditis, and the following tests should be performed: Direct inoculation of the pericardial fluid into double-strength liquid Kirchner culture medium at the bedside and culture for M tuberculosis. Biochemical tests to distinguish between an exudate and a transudate (fluid and serum protein; fluid and serum LDH). Indirect tests for tuberculous infection: ADA, IFN-, or lysozyme assay. Pericardial biopsy "Therapeutic" biopsy: as part of surgical drainage in patients with severe tamponade relapsing after pericardiocentesis. Diagnostic biopsy: in areas in which TB is endemic, a diagnostic biopsy is not required before commencing empirical antituberculosis treatment. In areas in which TB is not endemic, a diagnostic biopsy is recommended in patients with >3 weeks of illness and without etiologic diagnosis having been reached by other tests.3 Empirical antituberculosis chemotherapy Tuberculosis endemic in the population: trial of empirical antituberculous chemotherapy is recommended for exudative pericardial effusion, after other causes such as malignancy, uremia, and trauma have been excluded. Tuberculosis not endemic in the population: when systematic investigation fails to yield a diagnosis of tuberculous pericarditis, there is no justification for starting antituberculosis treatment empirically.

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