Tuberculous Pericarditis

by Sam Malone

Pericarditis is a condition where the sac surrounding the heart, the pericardium, becomes swollen and inflamed. Pericarditis is classified as acute pericarditis or chronic pericarditis, with the former occurring suddenly and the latter being a long term condition. Acute pericarditis is the most common form of pericarditis with milder cases usually clearing up on their own and the more severe ones requiring medical intervention including hospitalization. Chronic pericarditis can often lead to constrictive pericarditis, a condition where the sac surrounding the heart becomes tight and loses its elasticity due to the presence of scar tissue. The tightened sac constricts the heart and can interfere with the normal functioning of the heart.

Tuberculous pericarditis is caused by the mycobacterium tuberculosis, the same organism that causes tuberculosis (TB). The spread of the tuberculosis outside the lung tissue to the pericardium results in a granulomatous pericarditis that can result in bleeding. In chronic cases, the bleeding can result in fibrosis due to scar tissue and calcification, resulting in constrictive pericarditis.

Tuberculous pericarditis can be divided into four stages. These are:
  • The dry phase
  • The effusive phase
  • The absorptive phase
  • The constrictive phase
The dry phase of infection is not easily recognizable. The earliest phase of pericardial infection is detected due to inflammation of the pericardium. The inflammatory process is thought to develop as a hypersensitive reaction to the presence of tuberculoprotein, with low levels of tubercle bacilli being present. The pericardial fluid at this stage contains leukocytes and high protein concentration.

About half of all patients who present symptoms of the effusive phase resorb the effusion, with symptoms usually resolving without medical intervention. This usually happens over a 2 to 4 week period. In other cases the disease progresses to the constrictive phase.

The signs and symptoms of chronic tuberculous pericarditis may include:
  • A sharp chest pain
  • A stabbing pain in the left side of the chest
  • A persistent cough
  • Fever
  • Night sweats
  • Fatigue and feelings of weakness
  • Unexplained weight loss
  • Breathing difficulty
  • Swelling in the abdomen
The symptoms are not as specific and may just start out with fever, night sweats and weight loss. It  may be followed by difficulty in breathing and chest pains. The symptoms will depend on how much the pericardium is involved and the degree to which the tuberculosis has spread.
The treatment for tuberculous pericarditis is the same as that for tuberculosis. Anti-tuberculous therapy is acknowledged as the most effective treatment to prevent the development of constrictive pericarditis and to reduce the risk of death.

Anti-tuberculous therapy is a four drug regimen that includes:
  • Isoniazid (300mg orally, once daily)
  • Rifampin (600 mg, once daily)
  • Pyrazinamide (15 to 30 mg/kg up to a maximum of 2 g/day as a single dose)
  • Ethambutol (15 to 25 mg/kg orally, once daily) or streptomycin (20 to 40 mg/kg up to a maximum of 1 g/day given intramuscularly)
These four drugs are continued for at least eight weeks before being gradually reduced with isoniazid and rifampin being continued for six months.

Studies have shown that in cases of individuals with active constrictive pericarditis, corticosteroids added to the four anti-tuberculous medications can reduce the risk of death and the need for pericardiectomy.

Pericardiectomy is usually needed in case of individuals who suffer from recurrent effusions or for the continued elevation of central venous pressure. The success rate for this procedure depends on the stage of the tuberculous pericarditis, and individuals suffering from end-stage constrictive disease usually being unable to tolerate the procedure.

References:    
  1. http://cmbi.bjmu.edu.cn/uptodate/pediatric%20cardiology/Pericardial%20disease/Tuberculous%20pericarditis.htm
  2. http://www.ncbi.nlm.nih.gov/pubmed/11528565

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