Tuberculous Pericarditis

Tuberculous pericarditis is infection of the pericardium by Mycobacterium tuberculosis, producing effusive, effusive constrictive or constrictive disease. It is the commonest cause of pericardial disease in Africa and is strongly linked to HIV.

• Spread is by contiguity from lung and lymph nodes or by haematogenous seeding.
• Mortality is 17 to 40 percent without treatment; constriction develops in about 30 to 60 percent of cases.

Subacute cough, dyspnoea, chest pain, fever, night sweats, weight loss, orthopnoea, and leg swelling.

• Signs: raised jugular venous pressure with Kussmaul sign, muffled heart sounds, pericardial rub, pulsus paradoxus, hepatomegaly, ascites, hypotension in tamponade.
• Differential diagnosis: viral and idiopathic pericarditis, malignant effusion, uraemic pericarditis, heart failure, dilated cardiomyopathy, purulent pericarditis, hypothyroidism, connective tissue disease, post myocardial infarction, radiation pericarditis, constrictive disease from other causes.
• Complications: cardiac tamponade, constrictive pericarditis, effusive constrictive pericarditis, heart failure, arrhythmia, dissemination.

Echocardiography is the key test.

• ECG (low voltage, ST changes, electrical alternans), chest radiograph (globular heart, pulmonary tuberculosis, pleural effusion), echocardiography (effusion, fibrin strands, thickened pericardium, tamponade physiology, constriction).
• Pericardiocentesis: exudate, lymphocytes, adenosine deaminase over 40 U/L, Xpert MTB/RIF Ultra and culture; pericardial biopsy where available.
• Sputum Xpert, HIV test and CD4, urine lipoarabinomannan, full blood count, renal function, thyroid function.
• Cardiac MRI or CT for constriction.

Six months of antituberculous therapy, with steroids in selected patients and early drainage for tamponade.

• Supportive: bed rest with monitoring in tamponade, salt restriction, fluid management, avoid diuretics in tamponade, nutrition, oxygen.
• Pharmacological: 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol then 4 months of isoniazid and rifampicin (daily doses isoniazid 5 mg/kg, rifampicin 10 mg/kg, pyrazinamide 25 mg/kg, ethambutol 15 mg/kg), with pyridoxine 25 to 50 mg daily. Prednisolone in HIV negative patients: 1 mg/kg daily (usual 60 mg) for 4 weeks, 30 mg for 4 weeks, 15 mg for 2 weeks, 5 mg for 1 week, to reduce tamponade and constriction; in HIV positive patients, steroids carry risk of HIV related malignancy and infection, so use only after specialist judgement. Antiretroviral therapy within 2 weeks if CD4 under 50, otherwise by 8 weeks; dolutegravir 50 mg twice daily with rifampicin. Cotrimoxazole 960 mg daily.
• Procedures: urgent pericardiocentesis for tamponade (and for diagnosis), with a pigtail drain left in until output is under 50 mL/day; pericardiectomy for persistent constriction after 6 to 8 weeks of therapy or for effusive constrictive disease with failure.
• Special groups: pregnancy, first line regimen with pyridoxine; children, weight band dosing and prednisolone 1 mg/kg daily for 4 weeks then tapered over 6 to 8 weeks; HIV, close surveillance for immune reconstitution inflammatory syndrome and Kaposi sarcoma; constrictive disease, diuretics (furosemide 40 mg daily) to relieve congestion.
• Red flags: hypotension, rising jugular venous pressure, pulsus paradoxus, syncope, oliguria, recurrent effusion, signs of constriction after 6 weeks of therapy.
• Follow-up: echocardiography at 2 weeks, 2 months and 6 months; review for constriction every 3 months for 1 to 2 years.