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Tuberculous pericardial effusion

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Tuberculous pericardial effusion

  1. 1. Tuberculous Pericardial effusion Dr Saleh Ahmed Ador MD Phase A, Cardiology NICVD, Dhaka.
  2. 2. • Cardiovusculer involvement is relatively uncommon in patient with TB and has been described 1-2% of patient • It mainly affect the pericardium • Although cardiovusculer involvement is secondary to TB elsewhere in the body it may be the only clinical menifestation of TB
  3. 3. Pericardial TB present as • Acute Pericarditis • Pericardial Effusion • Cardiac Temponade • Chronic Constrictive Pericarditis
  4. 4. Stage of TB Pericarditis • Dry stage • Effusion stage • Absoptive stage • Constrictive stage Mortality rate of acute pericarditis is more than 80% in acute stage and still more later stage due to constrictive pericarditis
  5. 5. • Pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. • Normal levels of pericardial fluid are from 15 to 50 ml
  6. 6. Pathogenesis • Pericardial involvement most commonly result from direct extension from of infection from adjacent mediastinal lymph node but occasionally be haematogenous, e.g. in milliary TB • While acute pericarditis appear to be hypersensitivity reaction to tuberculoprotein chronic pericarditis reflect granuloma formation which then progress to fibrosis and then calcification
  7. 7. Symptoms • Low grade fever • Malaise • Night sweats • Cough • Weight loss • Retrosternal discomfort • Palpitation • Breathlessness on exertion or even at rest • Orthopnoea
  8. 8. Examination General Examination: • Fever • Pulse – low volume, trachycardia, pulsus paradoxus may be present • Hypotension • JVP- raised, kussmaul’s sign positive
  9. 9. Precordium examination: • Fullness of intercostal space • Apex beat is difficult to palpate • Area of cardiac dullness increased on purcussion • Heart sounds are muffled or distant Abdomen examination: • Liver is enlarged and tender • Ascitis Respiratory system examination: • Bronchial breath sound at left inferior angle of scapula (Ewart’s sign) due to compression of base of left lung by enlarged heart
  10. 10. Investigation 1. Chest Xray AP view: •Globular enlargement of the cardiac shadow giving a water bottle configuration •Widening of the subcarinal angle •Oligaemic lung field
  11. 11. 2. Chest X ray lateral view A vertical opaque line separating a vertical lucent line directly behind the sternum (Oreo cookie sign)
  12. 12. 3. ECG • Low voltage ECG • Tachycardia • Electrical alternans • T inversion
  13. 13. Electrical altrnans Low voltage ECG
  14. 14. 4. Echocardiography: Presence of echo free space between epicardium and paricardium
  15. 15. 5. CXR trendelenberg position – base of the heart will be wide 6. Sputum smear and culture 7. MT positive in 80 -100 % case 8. CT scan –used to demonstrate pericardial thickening with fluid
  16. 16. 9. Pericardiocentesis: • Done for both diagnosis and relief of symptoms • Straw coloured or sarosanguinous • Exudative • Lymphocytic predominant on cytology • ADA >30 U/L • AFB may be found on pericardial fluid
  17. 17. 10.Pericardial biopsy: • Done by thoracotomy or percutaneously using a bioptome • Histology shows granulomatous lesion • Shows positive result in upto 70% cases • Nonspecific histological change doesn’t exclude TB • Pericardial tissue culture can be done for Tuberculosis
  18. 18. Treatment Medical management: CAT-1 anti TB regiment: • 4FDC (HRZE) -2 month • 2FDC (HR)- 4 month Corticosteroid therapy: • Improve rapid resolution of pericardial fluid • Reduce need for repeated pericardiocentasis • Reduce need for surgery • Reduce mortality
  19. 19. • Dose- Tab Prednisolone • 60mg/day for 4 weeks • 30mg/day for 4 weeks • 15mg/day for 2 weeks • 5mg/day for 1 week
  20. 20. Surgical management: • Those with late presentation of constriction or calcification • Those who have life threatening tamponade at any stage • Who fail to respond to the initial 6-8 month of medical treatment • Have a raise venous pressure Procedure: – Pericardiectomy producing a pericardial window for pericardial thickening
  21. 21. Complications • Constrictive pericarditis • Cardiac temponade • Chronic heart failure • Recurrent pericarditis • Bacterial infection
  22. 22. Characteristic Cardiac temponade Constrictive pericarditis Pulsus paradoxus Present Absent Kussmaul’s sign Absent Present Electrical alternans in ECG Present Absent Echocardiography Thickened pericardium Pericardial calcification Absent Present Pericardial effusion Present Absent Right atrial collapse Present Absent
  23. 23. Role of Cadiologists: • Diagnosis by Echocardiography • Pericardiocentesis Role of Pulmonologists : • Medical management of tuberculous pericardial effusion • Idendify the primary source Role of Thorasic surgeons: • Pericardiectomy for pericardial thickening
  24. 24. • Tuberculous pericardial effusion is always secondary involvement of primary TB • Early detection and management can prevent grave complication like cardiac temponade • Cardiologists, pulmonologists and thorasic surgeon are needed for comprehensive management of this patient

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