Date post: | 26-Mar-2015 |
Category: |
Documents |
Upload: | aaliyah-mason |
View: | 219 times |
Download: | 2 times |
Interesting Case Rounds
Nicole Kirkpatrick
February 7, 2008
Case 25 y.o. first nations male CC: RUQ pain and SOB
HPI SOBOE X 4 weeks, gradually worsening Cough RUQ pain X 3 days Constant pain, non-radiating No nausea, vomiting or diarrhea No peripheral edema, no orthopnea No recent travel, no sick contacts Not immunocompromised Fever, night sweats and weight loss
HPI PMH - healthy PSH - none Medications - none Allergies - none Smoker ETOH -15 beers/w Marijuana use
Vital signs HR 105 BP 110/80 RR 25 T 38 SpO2 98% on R/A
Physical exam Thin, no icterus noted CVS
JVP ~8cm, does not vary with respiration Normal S1, S2, no extra HS appreciated Decrease in SBP of 8mmHg on inspiration Mild peripheral edema
RESP Clear
ABD Soft Liver edge palpable ~4 cm below CM Tender in RUQ Spleen not palpable No peritoneal findings No shifting dullness
Investigations?
Investigations Blood work
Hb normal WBC slightly elevated Normal electrolytes Normal renal function ALT slightly elevated
Investigations ECG
Sinus tachycardia Low voltage
Investigations CXR
Chest X-ray
Thoughts?
Differential Infection
Viral (coxsackie A,B, HIV, Hepatitis), Bacterial (pneumococcus, streptococcus, staphylococcus, TB,Neisseria,Legionnella), Fungal (histoplasmosis, coccidioidomycosis), Parasitic
Inflammation RA, SLE, AS, Scleroderma, ARF, Wegner’s
Metabolic Uremia, Hypothyroidism
Neoplastic Primary or Metastatic (Lung, Breast, Lymphoma, Leukemia)
Drug-related Procainamide, INH, Hydralazine, Minoxidil, Phenytoin)
Irradiation Trauma Dressler’s
Initial management
Management Transferred to larger centre for definitive
diagnosis ECHO Pericardiocentesis Pericardial biopsy
Diagnosis Tuberculous pericarditis
Objectives Review TB
Epidemiology Presentations
TB pericarditis Epidemiology Presentation Diagnosis Treatment
Mycobacterium tuberculosis
Tuberculosis Mycobacterium tuberculosis
Aerobic, non-spore forming, slow growing bacillus
Humans are the only reservoir Other Mycobacterium spp.
World Incidence of TB
> 300100 - 29950 - 9925 - 49< 24No data
Source: 2005 WHO (maps.maplecroft.com)
Incidence per 100,000 pop / year
Tuberculosis Primary infection
Infected through droplet transmission Host defenses kill bacteria and prevent active
disease Latent TB
Due to bacilli that survive host defenses and are carried to LN where they can survive for years
Reactivation Occurs when host immune system is not capable
of containing foci of latent infection
Tuberculosis and HIV Increased risk of:
Primary disease becoming active infection Reactivation
5-10% per year Extrapulmonary TB
WHO Estimates of TB (2005) Incidence: 8.8 million worldwide
Canada 5 cases / 100,000 (1616 total)
Prevalence: 14 million
Tuberculous Pericarditis
Leading cause of pericarditis in African and Asia
Occurs in 1-2% of patients with pulmonary TB Commonly due to reactivation with no
obvious primary focus Accounted for 70% of cases referred for
diagnostic pericardiocentesis in SA series 4% in the developed world
Tuberculous Pericarditis Pericardium involved via
Retrograde lymphatic spread Peritracheal, peribronchial, mediastinal LN
Contiguous spread from adjacent lesion Lung, pleurae, ribs, diaphragm, peritoneum
Hematogenous spread
Tuberculous Pericarditis Four pathological stages
DRY Isolated granulomas
EFFUSIVE Serosanginous effusion with lymphocytic exudate
ABSORPTIVE Absorption of effusion and resolution of symptoms
without treatment CONSTRICTIVE
Fibrosis of visceral and parietal pericardium +/- effusion
Tuberculous Pericarditis Mortality
80-90% in pre-antibiotic era 8-17% in HIV negative patients 17-34% in HIV positive patients
Tuberculous Pericarditis Three clinical presentations
Pericardial effusion (80%) Constrictive pericarditis (5%)
30-60% of patients progress to constrictive pericarditis
Effusion-constriction (15%)
Tuberculous Pericarditis Effusion
Bacilli penetrate pericardium Antigens on bacilli initiate a delayed
hypersensitivity reaction Lymphocytes release cytokines that
activate MP and induce granuloma formation
Often few bacilli found in pericardial fluid
Tuberculous Pericarditis Symptoms
Cough Dyspnea CP Night sweats Orthopnea Weight loss
Signs Tachycardia Fever JVD HSM Ascites Edema
Tuberculous Pericarditis Effusion
Tamponade Pulsus paradoxus Friction rub Indistinct apical impulse Distant heart sounds
Constriction Kussmaul’s Pericardial knock
Effusive-constriction Often apparent when RA pressure remains elevated after
fluid removal
Diagnosis Can be challenging Consider in patients
Pericarditis that does not resolve From TB endemic areas Work or Travel in endemic areas High risk populations
Diagnosis ECG
Non specific changes Low QRS voltage Diffuse T wave inversion Electrical alternans if large effusion Minority can present with acute ST and PR changes of acute
pericarditis CXR
May show pulmonary lesion Increased cardiac silhouette with pericardial effusion Pleural effusion Pulmonary venous congestion rare
Diagnosis ECHO Effusion
Fibrinous strands RA compression, RV diastolic collapse, abN
respiratory variation in tricuspic and mitral flow velocities, dilated venae cavae
Constriction Pericardial thickening Abnormal ventricular septal movement
Diagnosis Tuberculin Skin Test
Can be negative in up to 30% due to anergy
Diagnosis Pericardiocentesis and analysis of fluid
Exudative effusion AFB on smear (40-60%) Culture Other
PCR for Mycobacterium DNA Elevated adenosine deaminase Interferon gamma using ELISA
Diagnosis Pericardial biopsy
Stain tissue for AFB Histology
Granulomatous inflammation
Treatment Anti-tuberculous treatment
Early studies with Streptomycin showed decreased mortality and progression to constriction
INH, Rifampin, Pyrazinamide, Ethambutol X 2M INH, Rifampin X 4M
Quiz Multi-drug resistant TB (MDR-TB)
Resistant to INH and RIFAMPIN Extensively drug resistant TB (XDR-TB)
Resistant to INH and RIFAMPIN and to 3 of the 6 main classes of second line agents
Aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine, paraaminosalicyclic acid
Treatment Steroids
Still controversial Decrease mortality, need for
pericardiectomy
Treatment Pericardiectomy
After initiation of anti-tuberculous treatment
Back to the case Found to have Effusive-Constrictive
Pericarditis TB skin test negative Started on anti-tuberculous treatment Underwent pericardiectomy
Technically difficult, not able to completely remove pericardium
On-going difficulty with HF Work-up for transplant
Questions or Comments?
References Cherian, G. (2004). "Diagnosis of tuberculous aetiology in pericardial effusions." Postgrad Med J
80(943): 262-6. Mayosi, B. M., L. J. Burgess, et al. (2005). "Tuberculous pericarditis." Circulation 112(23): 3608-16. Mayosi, B. M., C. S. Wiysonge, et al. (2006). "Clinical characteristics and initial management of
patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry." BMC Infect Dis 6: 2.
Nardell, E. A., D. Fan, et al. (2004). "Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-2004. A 30-year-old woman with a pericardial effusion." N Engl J Med 351(3): 279-87.
Strang, J. I., A. J. Nunn, et al. (2004). "Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up." Qjm 97(8): 525-35.
Syed, F. F. and B. M. Mayosi (2007). "A modern approach to tuberculous pericarditis." Prog Cardiovasc Dis 50(3): 218-36.
Wragg, A. and J. I. Strang (2000). "Tuberculous pericarditis and HIV infection." Heart 84(2): 127-8. UpToDate eMedicine