Download Echocardiographic Features of Tuberculous Pericarditis

Case Report
Echocardiographic Features of
Tuberculous Pericarditis
J Chin Med Assoc
2003;66:612-614
Chang-Sheng Ku1
Kuan-Rau Chiou2,3
Shoa-Lin Lin2,3
Chun-Peng Liu2,3
Hung-Ting Chaing2,3
Echocardiography is a sensitive diagnostic tool for detecting pericardial effusion and
intrapericardial abnormalities. A-70-year old man was found to have tuberculous
pericarditis. The history and echocardiographic findings are reported, and relevant
literature is reviewed.
1
Division of Cardiology, Department of
Internal Medicine, Kaohsiung Military
General Hospital, Kaohsiung City
2
Division of Cardiology, Department of
Internal Medicine, Kaohsiung Veterans
General Hospital, Kaohsiung City
3
National Yang-Ming University School of
Medicine, Taipei, Taiwan, R.O.C.
Key Words
echocardiography;
pericarditis;
tuberculosis
chocardiography is a sensitive diagnostic tool for
detecting pericardial effusion and intrapericardial
abnormalities. Tuberculosis accounts for up to 4% of all
cases of acute pericarditis and 7% of cases of cardiac
tamponade. The mortality rate of tuberculosis still ranges
from 14% to 40%.1 In Taiwan, the prevalence rate of tuberculosis decreased from 1.02% in 1957 to 0.11% in
1987; however the prevalence seemed to have increased
again.2 We encountered a case with tuberculous pericarditis. The echocardiographic findings are reported
and relevant literature is reviewed.
E
CASE REPORT
A 70 year-old man had a history of intermittent low
grade fever and productive cough with mucoid sputum
for 2 months. The cough became severe and he was adReceived: January 20, 2003.
Accepted: June 25, 2003.
612
mitted for further examination and management. Physical examination at admission revealed a blood pressure
of 140/80 mmHg, heart rate of 86 per minute, and respiratory rate of 24 per minute. No significant palpable
mass was noted over both sides of the neck. Mild jugular
vein engorgement was also noted. The lungs were clear
but with diminished breathing sound over both lower
lung fields. The intensity of heart sounds was reduced,
and a pericardial friction rub was audible. Peripheral
pulses were intact. No peripheral edema, cyanosis, or
digital clubbing was found.
The chest X-ray examination showed cardiomegaly
and bilateral pleural effusion. The electrocardiogram
showed sinus tachycardia and generalized low voltage.
Two-dimensional echocardiography revealed a large
amount of pericardial effusion with thickened visceral
and parietal pericardium. In addition, there were many
linear, echo-dense, fibrous strands protruding into the
Correspondence to: Shoa-Lin Lin, MD, Division of Cardiology, Department of Internal Medicine,
Kaohsiung Veterans General Hospital, 386, Dar-Chung 1st Road, Kaohsiung City 813, Taiwan.
Fax: +886-7350-5220; E-mail: [email protected]
October 2003
TB Pericarditis
pericardial cavity (Figs. 1 and 2).
The fibrous strands showed undulating movements
resembling the fronds of a plant waving in the breeze, resulting in a to-and-fro motion during ventricular systole.
The dense layers of echo conglomerated into several linear dense structures protruding into the pericardial cavity
(Fig. 3). Echocardiography-guided pericardiocentesis
was performed. Gram stain and acid fast stain did not
find any bacteria, however, the biopsy of pleura showed
Fig. 3. The modified parasternal short-axis view at apical
level showed the linear fibrous strands bridging and protruding (arrow heads) into the pericardial cavity.
evidence of Mycobacterium tuberculosis (TB) infection.
The culture of the pericardial fluid was also positive for
TB 6 weeks later. The patient received anti-TB treatment
and was discharged subsequently with improved condition.
Fig. 1. The parasternal long-axis view of two-dimensional
echocardiogram showed the large amount of pericardial effusion (PE). The visceral and parietal pericardium were
thickened and formed a dense echo band (white and black
arrows). Several frond-like structures protruding into the
pericardial cavity were noted (arrow leads).
Fig. 2. The modified apical four-chamber view demonstrated the large amount of pericardial effusion (PE). The
frond-like structures were also found (arrow heads).
DISCUSSION
The diagnosis of tuberculous pericarditis is often
missed because of the difficulty in isolating the causative
organism. The incidence of tuberculous pericarditis
among patients with pulmonary tuberculosis ranges from
1 to 8%.3 Tuberculous pericarditis is a potentially lethal
manifestation of extrapulmonary tuberculous. The pericardial effusion is thought to be due to a hypersensitivity
reaction to tuberculoprotein.4 Pericarditis can result from
the rupture of adjacent involved lymph nodes or hematologic spread. Typically, the process begins as effusiveconstrictive disease and progresses into constrictive pericarditis without effusion. In the later stage, acid-fast bacilli are usually not detected, but caseating granulomas
involving the pericardium and epicardium may be present.5 Chia et al.6 reported their experience of intrapericardial abnormalities in association with tuberculous
pericardial effusion. They found linear frond-like intrapericadial echodense structures which showed undulating movements and were seen to conglomerate into a
613
Chang-Sheng Ku et al.
Journal of the Chinese Medical Association Vol. 66, No. 10
Table 1. The echocardiographic findings in patients with tuberculous pericarditis
Echo findings
References
Small/moderate/large amount of pericardial effusion
Cardiac tamponade
Fibrin strand/mass-like exudate
Thickened pericardium
Constrictive pericarditis
Permanyer et al.5 Chia et al.,6 Ko et al.,7 Horowitz et al.,10 Scully et al.11
Fowler et al.,1 Horowitz et al.10
Chia et al.,6 Ko et al.7
Hinds et al.8
Anonymous et al.,2 Lorell et al.,3 Suwan et al.9
dense mass protruding into the pericardial cavity. Ko et
al.7 considered that frond-like structures and pericardial
thickening seen on echocardiography might be characteristics in patients with tuberculous pericarditis and indicated early institution of antituberculous therapy. Although echocardiographic features of tuberculous pericarditis include visceral pericardial thickening, with a
shaggy layer of material that is presumably fibrinous
exudates, they are not specific. Similar echocardiographic
findings may occur in patients with chronic renal disease,
malignant tumor metastasis to the pericardial space, or in
patients undergoing radiation therapy. Careful historytaking and physical examination usually can differentiate
the tuberculous pericarditis from the above entities.
The chronic and recurrent pericardial processes are
most likely to develop adhesive or fibrinous pericardial
bands. Besides, thickened pericardium8 or signs of constrictive pericarditis9 and cardiac tamponade1,10 have
been reported in patients with tuberculous pericariditis.
Furthermore, in previous studies, small to large amount
of pericardial effusion were also observed in these kind
of patients.5-7,10,11 Eechocadiographic findings of tuberculous pericarditis are summarized in Table 1.
The diagnosis of tuberculous pericarditis based on
findings of acid-fast organisms in the pericardial fluid is
often difficult. Four to 6 weeks is often required for the
culture of the bacilli from a pericardial effusion. This
case received pericardial fluid evaluation, the gram stain
and acid fast stain did not find any bacteria. The tuberculosis was diagnosed after culture of the pericardial fluid.
Pericardial biopsy is useful to assess the histologic features of pericardial tissue; it is a more sensitive technique
in confirming the tuberculosis infection.9
In conclusion, this report describes the possible
echocardiographic findings of tuberculous pericarditis.
Aggressive study is indicated to confirm the possibility
614
of tuberculous pericaditis if there is evidence of a massive pericardial effusion with fibrous strands and thickened pericardium.
REFERENCES
1. Fowler NO. Tuberculous pericarditis. JAMA 1991;266:99-103.
2. Anonymous. Tuberculosis in Taiwan: 7th Prevalence Survey.
Taiwan Provincial Tuberculosis Bureau (in Chinese). Taiwan,
1990;1-29.
3. Lorell BH, Braunwald E. Pericardial disease. Braunwald E. In:
Heart disease. 4th ed. Philadelphia: Saunders WB 1992;
1456-507.
4. Agrawal S, Radhakrishnan S, Sinha N. Echocardiographic
demonstration of resolving intrapericardial mass in tuberculous pericardial effusion. Intern J Cardiol 1990;26:240-l.
5. Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623-30.
6. Chia BL, Choo M, Tan A, Ee B. Echocardiographic abnormalities in tuberculous pericardial effusion. Am Heart J 1984;
l07:1034-5.
7. Ko SC, Liaw YS, Yang PC. Ultrasonographic demonstration
of intrapericardial fibrous layers in tuberculous pericarditis:
report of a case. J Med Ultrasound 1998;6:186-9.
8. Hinds SW, Reisner SA, Amico AF, Melter RS. Diagnosis of
pericardial abnormalities by 2D-echo: a pathology-echocardiography correlation in 85 patients. Am Heart J 1992;
123:143-50.
9. Suwan PK, Potjalongsilp S. Predictors of constrictive pericarditis after tuberculous pericarditis. Br Heart J 1995;73:
187-9.
10. Horowitz MS, Schultz CS, Stinson EB, Harrison DC, Poop
RL. Sensitivity and specificity of echocardiographic diagnosis
of pericardial effusion. Circulation 1974;50:239-47.
11. Scully RE, Mark EJ, McNeely WF, Ebeling SH, Phillips LD.
Weekly clinicopathological exercises. N Engl J Med 1997;
19:1812-9.