Transcript TB PERICARDITIS -Odette Tolentino

Medical Grandrounds
Odessa Tolentino-Wilson, MD
October 25, 2007
Objectives:
• To present a case of TB
Pericarditis
• To discuss the pathogenesis,
diagnosis, and management of
TB pericarditis
• To discuss updates in the
management of TB Pericarditis
Identifying Data
•
•
•
•
•
R.T.
51 y/o, male
Filipino
Married
Quezon City
Chief Complaint
• Shortness of breath
History of Present Illness
1 month PTA
 generalized body
weakness
undocumented fever
 Right upper back pain with
radiation to the left
History of Present Illness
17 days PTA
 easy fatigability
 shortness of breath
 3 pillow orthopnea
History of Present Illness
Consult
2D Echo: Large to massive
circumferential pericardial
effusion with no evidence of
tamponade
Ejection Fraction: 76%
History of Present Illness
 admitted
Diagnostic pericardiocentesis:
580 cc red turbid fluid
• Gram stain: no microorganisms seen
• Direct AFB stain: no acid fast bacilli
seen
• Routine culture: pending
• Fungal culture: pending
• AFB culture: pending
• Final cytopathologic diagnosis:
Pericardial fluid; smears and cell
block showing lymphocytes,
macrophages, and some mesothelial
cells
History of Present Illness
1 week PTA
 easy fatigability, shortness of
breath, orthopnea
History of Present Illness
1 day PTA
 progressive shortness of
breath
 follow up
History of Present Illness
 2 d echo: Large organized
fluid with thickened pericardium
but no evidence of constriction
or tamponade.
Ejection Fraction: 64%
 advised admission
Review of systems
(-)headache
(-)dizziness
(-)fever
(-)cough
(-)hemoptysis
(-)vomiting
(-)chest pain
(-)palpitations
(-)dysuria
(-)polyuria
(-)nocturia
(-)oliguria
(-)abdominal pain
(-)constipation
(+)weight loss
Past Medical History
• Hypertension x 10 years
– Metoprolol 50 mg BID
– Nifedipine 30 mg OD
• Diabetes Mellitus x 1 year
– Gliclazide 30 mg 2 tablets daily
• CKD x 1 year
– Ketosteril 2 tablets TID
– Epoeitin alpha 4000 units SC 1x/week
• No Bronchial Asthma
• No Pulmonary TB
Family History
(+) Diabetes Mellitus
(+) Hypertension
Personal/Social History
• Previous smoker (10 pack years)
• Previous alcoholic beverage
drinker
Physical examination
• Conscious, coherent, weak looking,
not in distress
• BP 150/90 HR 87 RR 19 T37.2C
• Pale palpebral conjunctivae, anicteric
sclearae, no tonsillopharyngeal
congestion, no neck vein distention,
no cervical lymphadenopathy
• Symmetric chest expansion,
decreased tactile fremitus, both
bases, decreased breath sounds both
bases, more on the right
Physical examination
• Adynamic precordium, normal rate,
regular rhythm, muffled heart
sounds, AB 5th ICS LMCL, (-)murmur
• Flabby, normoactive bowel sounds,
tympanitic, soft, no tenderness, no
organomegaly
• Grade 2 bipedal edema, full and
equal pulses
Salient Features
• 51 y/o, Filipino, male
• Progressive shortness of breath
• Generalized body weakness, undocumented
fever, easy fatigability, 3 pillow orthopnea,
weight loss
• Decreased breath sounds, both bases, more
on the right
• Muffled heart sounds, pericardial friction
rub
• Bipedal edema
• Recurrent pericardial effusion
• Hypertension, diabetes, CKD
Admitting Impression
• Recurrent Pericardial Effusion,
etiology to be determined
• Hypertensive Cardiovascular
Disease
• Diabetes Mellitus Type 2, NIR
• Chronic Kidney Disease
secondary to Diabetic vs
Hypertensive Nephrosclerosis
Pericardial Effusion /
Pleural Effusion
Malignancy
Infectious Pericarditis
Viral/Idiopathic
Bacterial
Tuberculous
Uremic Pericarditis
Course in
the wards
On Admission
• Oxygen at 2-3 lpm
via nasal cannula
pO2
72.8
pH
7.4
pCO2
27.3
HCO3
16.8
O2 Sat
95
Base excess -6.1
TCO2
17.7
RR
26
2-3 lpm
Hgb
8.9
K
3.4
Hct
27.4
Crea
2.8
WBC
7490
Alb
1.9
Seg
76
Lym
13
Protime
Mono
10
Act
58.4%
Eos
1
INR
1.4
Plt Ct
538,000
• Yellow, hazy, acidic 5.0, ph 1.025,
sugar trace, CHON trace, ketones
negative, nitrites negative, leucocyte
esterase neg, blood trace, rbc 1.4,
wbc 8.1, epithelial cells 3.2, Bact
1151.7
On Admission
• Referred to TCVS
•
•
•
•
Hgb 8.9; Hct 27.4
Transfused with 1 unit PRBC
Hgb 10.9 ; Hct 33
Fecal Occult Blood Test: negative
• Epoietin alpha 4000 units SQ
1x week
• Metoprolol 50 mg BID
• Amlodipine 5 mg OD
1st Hospital Day
• Pericardiostomy tube insertion
with Pericardial biopsy
• Chest tube insertion, Right lung
• Cefuroxime 750 mg IV q8
• Pericardial Fluid analysis:
– No microorganisms seen,
pus cells 0-1, epithelial cells 1-2
– Negative AFB
– Culture: No growth in 5 days
• Pleural fluid analysis:
– Negative AFB
– Culture: oxacillin resistant coagulase
negative staphylococcus
• Linezolid 600 mg IV q12
2nd Hospital Day
• CT scan of the chest and the
abdomen
Impression:
CT scan of the chest:
• S/P placement of the right thoracotomy and
pericardostomy drainage catheters
• Subsegmental atelectasis organizing
consolidation pneumonia, right lower lobe
• Moderate pleural effusion, left hemithorax
with complete atelectasis of the left lower
lobe.
• Mild cardiomegaly
• Residual pericardial effusion with minimal
pericardial emphysema which may be post
surgical in nature
• Nonspecific mediastinal lymphadenopathy
• Minimal subcutaneous emphysema, right
lateral chest wall.
CT scan of the Abdomen: No oral or
intravenous contrast were given
• Minimal ascites.
• Consider gastric ileus.
• Perinephric fat stranding which may
be due to an inflammatory/infectious
process.
• Mild atherosclerotic disease, coronary
vessels, abdominal aorta and
common iliac arteries.
Pericardial Effusion /
Pleural Effusion
Malignancy
Infectious Pericarditis
Viral/Idiopathic
Bacteria
Tuberculous
Uremic Pericarditis
Course in the Wards
• Referred to Endocrinology
service
– CBG monitoring
– Repaglinide 0.5 mg TID ac meals
1600
1400
1200
1000
CTT
800
Pericardiostomy
600
400
200
0
D1 D2 D3 D4 D5 D6
Figure 1. CT tube and Pericardiostomy tube drain
6th Hospital Day
Hgb
Hct
WBC
10.1
32.4
9840
Seg
Lym
Mono
Plt Ct
85
6
9
515,000
• Pericardiostomy
tube pulled out
• Right Chest tube
was hooked to
Heimlich valve
• Iberet Folic BID
• Pericardial biopsy: caseating
granuloma consistent with
tuberculosis
– Referred to Infectious Disease
• Ethambutol HCL 275mg/tab 4
tablets/day
• Rifampicin 150mg/tab 4 tablets/day
• INH 75 mg/tab 4 tablets/day
• Pyrazinamide 400 mg/tab 4
tablets/day
Pericardial Effusion /
Pleural Effusion
Malignancy
Infectious Pericarditis
Viral/Idiopathic
Bacteria
Tuberculous
Uremic Pericarditis
Clinical Outcome
• Discharged improved on the 8th
hospital day
• Readmitted for Pericardiectomy
FINAL DIAGNOSIS:
TB pericarditis, pericardial effusion
secondary
Hypertensive Atherosclerotic Cardiovascular
Disease
Diabetes Mellitus, type 2, poorly controlled,
NIR
Chronic Kidney Disease secondary to Diabetic
Nephropathy vs Hypertensive
Nephrosclerosis, Acute Kidney Injury,
resolved
Hypoalbuminemia, multifactorial
Hyponatremia, multifactorial
Discussion
Tuberculosis
In 1993, the World Health Organization
(WHO) declared TB to be a global public
health emergency
Most common cause of infection-related death
worldwide
Discussion
..”nearly 2 billion
people, one-third
of the world's
population, have
Tuberculosis..”
• Philippines has the
ninth highest
burden of
tuberculosis in the
world
–
World Health Organization (WHO) Global TB
Report 2006
TB in the Philippines
• TB is the sixth greatest cause of morbidity
and mortality
• Approximately 78 Filipinos die from the
disease every day
• By 2004, the country achieved a TB case
detection rate of 73 %, exceeding the
national and global target of 70 %
• The National TB treatment success rate is
currently at 88 % above the national target
of 85 %
World Health Organization (WHO) Global TB Report 2006
Tuberculosis
TB Pericarditis
• Inflammation of the pericardium
caused by Mycobacterium
tuberculosis
• rare but life-threatening form of
extrapulmonary tuberculosis
Incidence
• TB has been reported to be the cause
of acute pericarditis in 4% of patients
in the developed world and 60% to
80% of the patients in the developing
world
• TB pericarditis has been estimated to
occur in 1-8% patients with
pulmonary tuberculosis
Clinical Manifestations
• Symptoms:
– nonspecific:
• fever, weight loss, and night
sweats.
• Symptoms depend upon the
stage of infection, the degree of
pericardial involvement, and the
degree of extrapericardial
tuberculous disease
In one series, the following
frequency of symptoms was noted:
• Cough — 94 percent
• Dyspnea — 88 percent
• Chest pain —76 percent
• Night sweats — 56 percent
• Orthopnea — 53 percent
• Weight loss — 48 percent
TB Pericarditis
• “Definite”
– tubercle bacilli in pericardial fluid or on a
histological section of the pericardium
• “Probable"
– proof of tuberculosis elsewhere in a
patient with otherwise unexplained
pericarditis
– a lymphocytic pericardial exudate with
elevated adenosine deaminase levels
and/or
– appropriate response to a trial of
antituberculosis chemotherapy
•
•
•
•
Acute pericarditis
Chronic pericardial effusion
Cardiac tamponade
Pericardial constriction
Routes of Spread
• Retrograde lymphatic spread of
M tuberculosis from peritracheal,
peribronchial, or mediastinal lymph
nodes
• Hematogenous spread from
primary tuberculous infection
• Direct extension of infection from
adjacent mediastinal lymph nodes
Four pathological stages of
tuberculous pericarditis:
(1) fibrinous exudation with initial
polymorphonuclear leukocytosis,
relatively abundant mycobacteria,
and early granuloma formation with
loose organization of macrophages
and T cells
(2) serosanguineous effusion with a
predominantly lymphocytic exudate
with monocytes and foam cells
(3) absorption of effusion with
organization of granulomatous
caseation and pericardial thickening
caused by fibrin, collagenosis, and
ultimately, fibrosis
(4) constrictive scarring the
fibrosing visceral and parietal
pericardium contracts on the cardiac
chambers and may become
calcified, encasing the heart in a
fibrocalcific skin that impedes
diastolic filling and causes the
classic syndrome of constrictive
pericarditis.
Integrated Etiologic Approach to
the Patient With Suspected
Tuberculous Pericardial Effusion
• Chest radiograph
– may reveal changes suggestive of
pulmonary tuberculosis in 30% of cases
• Electrocardiogram
– Low voltage QRS, inverted T waves
• Echocardiogram
– evidence of pericardial effusion
Mayosi et.al.Tuberculous Pericarditis. Circulation. 2005;112:36083616
Integrated Etiologic Approach to
the Patient With Suspected
Tuberculous Pericardial Effusion
• CT scan and/or MRI of the chest
– 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.
Mayosi et.al.Tuberculous Pericarditis Circulation.
2005;112:3608-3616
Integrated Etiologic Approach to
the Patient With Suspected
Tuberculous Pericardial Effusion
• Culture of sputum, gastric
aspirate, and/or urine
• Right scalene lymph node biopsy
if pericardial fluid is not
accessible and lymphadenopathy
is present
Mayosi et.al.Tuberculous Pericarditis Circulation.
2005;112:3608-3616
Integrated Etiologic Approach to
the Patient With Suspected
Tuberculous Pericardial Effusion
• Pericardiocentesis
– Therapeutic pericardiocentesis
• indicated in the presence of cardiac
tamponade.
– Diagnostic pericardiocentesis
• considered in all patients with
suspected tuberculous pericarditis
– Mayosi et.al.Tuberculous Pericarditis Circulation.
2005;112:3608-3616
Integrated Etiologic Approach to
the Patient With Suspected
Tuberculous Pericardial Effusion
• Pericardial biopsy
• Diagnostic biopsy:
– Not required in areas in which TB is endemic
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.
Mayosi et.al.Tuberculous Pericarditis Circulation.
2005;112:3608-3616
• Empirical antituberculosis chemotherapy
– In tuberculosis endemic population: trial of
empirical antituberculous chemotherapy is
recommended for exudative pericardial effusion,
after other causes such as malignancy, uremia,
and trauma have been excluded.
– If tuberculosis is 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
Mayosi et.al.Tuberculous Pericarditis Circulation.
2005;112:3608-3616
Treatment
• Randomized controlled trials:
– suggests that 6- to 9-month regimens that include
INH and RIF are effective
– Therefore, among patients with extrapulmonary
tuberculosis, a 6- to 9-month regimen (2
months of INH, RIF, PZA, and EMB followed
by 4--7 months of INH and RIF) is
recommended as initial therapy unless the
organisms are known or strongly suspected
of being resistant to the first-line drugs. If
PZA cannot be used in the initial phase, the
continuation phase must be increased to 7 months,
as described for pulmonary tuberculosis.
American Journal of Respiratory and Critical Care Medicine (2003;167:603--62)
Evidence-based guidelines for the treatment of
extrapulmonary tuberculosis
Site
Length of therapy
(mo)
Rating (duration)
6
A1
Bone and joint
6-9
A1
Pleural disease
6
A11
Pericarditis
6
A11
9-12
B11
Disseminated
disease
6
A11
Genitourinary TB
6
A11
Peritoneal
6
A11
Lymph node
CNS tuberculosis
including meningitis
American Journal of Respiratory and Critical Care Medicine (2003;167:603--62)
• Antibiotic treatment is the same as
for pulmonary tuberculosis.
• On antituberculous drugs, resolution
occurs in 2 to 3 months in 80% of
patients.
• In 20%, subacute constriction
develops, and in half of these
patients it resolves over a few
months, leaving 10% in whom
pericardiectomy is required.
Cardiac Tamponade as a manifestation of tuberculosis. South Med J
94(5):525-528, 2001. © 2001 Southern Medical Association
• Corticosteroid treatment is a useful
adjunct in treating some forms of
extrapulmonary tuberculosis,
specifically meningitis and pericarditis
caused by drug-susceptible
organisms.
American Journal of Respiratory and Critical Care Medicine (2003;167:603--62)
Evidence-based guidelines for adjunctive use of
corticosteroids in the treatment of extrapulmonary TB
Site
Corticosteroids
Rating
(corticosteroids)
Lymph node
Not Recommended
D111
Bone and joint
Not Recommended
D111
Pleural disease
Not Recommended
D1
Pericarditis
Strongly Recommended
A1
CNS tuberculosis
including meningitis
Strongly Recommended
A1
Disseminated disease
Not Recommended
D111
Genitourinary TB
Not Recommended
D111
Peritoneal
Not Recommended
D111
American Journal of Respiratory and Critical Care Medicine (2003;167:603--62)
• Corticosteroid treatment reduces the
need for repeated pericardiocentesis
for control of fluid accumulation (9%
vs 23%) and control of
hemodynamically threatening
effusion.
• In one study, treatment with
corticosteroids in fairly large doses
(60 mg/day for 4 weeks and 15
mg/day for 2 weeks) decreased
mortality from 11% in control cases
to 4% in treated cases.
Cardiac Tamponade as a manifestation of tuberculosis. South Med J 94(5):525-528, 2001.
© 2001 Southern Medical Association
• Pericardiectomies were less
frequently necessary in patients given
corticosteroids (30% in control
patients vs 11% in steroid-treated
patients)
• One-year follow-up of patients with
tuberculous pericarditis revealed that
constriction developed in 18% of
steroid-treated patients vs 83% who
did not receive steroids
Cardiac Tamponade as a manifestation of tuberculosis. South Med J 94(5):525-528, 2001.
© 2001 Southern Medical Association
THANK YOU!!!
Sept Sept Sept Sept Sept Sept
8
9
11
14
15
16
Na
K
133 131 125 123 128
3.4
3.7
BUN
52
Crea 2.8
2.6
3.7
4
47
2.6
1.7
4