clinical Study

Tuberculous Pericardial Effusion

Abstract
Tuberculous pericardial effusion is common in Afro-Asian countries. Since, the introduction of HIV infection, the incidence
of tuberculous pericardial effusion has increased not only in Afro-Asian countries but also the world over. It presents with
the usual features of tuberculous infection (low grade fever, loss of appetite, loss of weight) along with features of pericardial
effusion (dyspnea, cough and enlarged heart). The salient features of pericardial effusion are low volume pulse or even
pulsus paradoxus, raised jugular venous pressure Kussmaul’s sign, congestive hepatomegaly, ascites and edema over legs. In
massive pericardial effusion, patient may go into cardiac tamponade when patient is breathless, restless with poor volume
pulse (typical paradoxus), engorged neck veins, sinus tachycardia, fall in blood pressure. Urgent pericardial paracentesis is
warranted to reverse the hemodynamic changes with improvement in symptoms and signs. Laboratory tests reveal raised
absolute lymphocyte count, raised ESR, cardiomegaly on X-ray chest, low voltage and sinus tachycardia on ECG, Echo-free
space seen between two pericardial layers on 2D-echo with heart floating in pericardial sac. Diagnostic pericardial paracentesis
shows that pericardial fluid is lymphocytic exudate, with elevated ADA and IFN-g levels. Tubercle bacilli may be isolated
on culture, guinea pig inoculation and nowadays by PCR technique. For management of tuberculous pericardial effusion,
antituberculous treatment with four standard drugs is started. Pericardial paracentesis with needle or even open drainage is
useful in relieving symptoms and rapid recovery. Adjunctive corticosteroids are useful for rapid recovery and for prevention
of development of constrictive pericarditis.

Keywords: Nasopharynx, foreign bodies, sewing needle

T
his is a common cause of chronic pericardial common symptom and is attributable to compression
effusion particularly in Afro-Asian countries. of bronchi. Rarely, one may encounter hoarseness of
It has become more common since occurrence voice or difficulty in swallowing due to pressure on
of HIV infection. It is relatively less common in well- recurrent laryngeal nerve or esophagus (seen in massive
developed countries. (USA, UK, Canada, Europe). pericardial effusion).
Infection is either blood-borne or spread from On physical examination, patient looks, thin, emaciated,
neighboring structures like lymph nodes, lungs and febrile, dyspneic and usually in propped up position.
bronchi. The patient presents with general features of Pulse is small in volume or may have typical pulsus
tuberculosis such as low-grade fever, loss of appetite, paradoxus (poor volume in inspiration and slightly
loss of weight and fatigability, cough along with better volume in expiration). Blood pressure is on
features of pericardial effusion.1 lower side. There may be distension of neck veins with
presence of Kussmaul’s sign (Jugular venous pressure
Clinical features of pericardial effusion rising during inspiration and lower during expiration).
Symptoms vary according to the amount of pericardial There may be tender hepatomegaly and in some chronic
fluid which may vary from 150 ml to 1,000 ml. Dyspnea cases there is free fluid in abdomen (ascites). There is
is very common symptom and its severity will vary invariably pitting edema over both legs.2
according to the quantity of fluid. The dyspnea is due to Precordial examination may show slight bulging
compression of the adjacent lungs and bronchi. Patient (fullness of intercostal spaces), cardiac impulse and
feels worse in lying down position and feels better in other pulsations usually not visible. Apex beat may be
sitting and leaning forward as that posture reduces the just palpable. On percussion heart borders are enlarged.
compression of lungs and bronchi. Cough is another On left side, one may get dull percussion note beyond
apex beat; on right side, one gets dull percussion note on
right side of the sternum particularly in 5th intercostal
Dept. of Medicine, Jaslok Hospital and Research Centre, Mumbai
Address for correspondence space (Rotch’s sign). One may be able to demonstrate
Dr GS Sainani shifting dullness in left second space which is dull in
201, Buena Vista
Gen. Jagannath Bhosle Road, Mumbai - 400 021 recumbent position and becomes less dull in sitting
E-mail: [email protected] position due to shifting of fluid down. In some cases

Indian Journal of Clinical Practice, Vol. 22, No. 8, January 2012 371
clinical study

of massive pericardial effusion, one can demonstrate disease5 and few reports on MRI findings in
Ewart’s sign (Dull note along with bronchial breathing tuberculous pericarditis are available.6,7
and egophony over left infrascapular region due to  ECG: There is low voltage and sinus tachycardia,
compression of the lower lobe of left lung by pericardial T waves are usually inverted.
fluid). On auscultation, heart sounds are distant. Rarely,  Echocardiography: This is most useful and
one may hear a pericardial rub.2 confirmatory as one sees echo-free space between
In massive pericardial effusion, patient may drift into two pericardial layers. In massive pericardial
cardiac tamponade, which should be recognized and effusions, one would see heart floating in pericardial
managed, on emergent basis. The clinical features of sac.2
tamponade are due to impaired diastolic filling leading  Cardiac catheterization: Before the advent of
to low cardiac output due to increased intrapericardial 2D-echo, cardiac catheterization and ventricular
pressure. It should be stressed that presentation of angiography used to be done to confirm and
cardiac tamponade is due to rapidity with which the evaluate the severity of pericardial effusion.2
fluid collects rather than total quantity of fluid. If fluid  Diagnostitic pericardial paracentesis: Pericardial
starts collecting gradually over a long period, the heart paracentesis for diagnositic and therapeutic
adopts and cardiac tamponade does not develop. But purposes are carried out under echocardiographic
if fluid collects rapidly, ventricular filling is impaired scanning. On aspiration, the fluid is straw colored
which leads to increase in diastolic pressure resulting or sometimes blood tinged. The fluid is sent for
in rise in atrial pressure, fall in stroke volume and cytology, biochemistry, Ziehl-Neelson stain and
cardiac output. That is reflected in compensatory sinus culture for tubercle bacilli. Guinea pig inoculation
tachycardia and fall in systolic blood pressure. Increase may confirm tuberculous etiology. The fluid is
in atrial pressures leads to rise in jugular venous lymphocytic exudate. (Proteins are increased
and there is predominance of lymphocytes). For
pressure. Patient gets severe breathlessness in recumbent
therapeutic purposes, it is carried out in cardiac
position (orthopnea) and he finds some comfort in
tamponade to relieve dyspnea, palpitation.2
sitting position and leaning forward. He may develop
cyanosis. Heart sounds are distant and one may hear III Gibbs et al8 in their survey of 10 years experience of
heart sound. Pericardial paracentesis (preferably under patients of pericardial effusion (who were managed by
echocardiographic guidance) is urgently warranted to percutaneous paracentesis) had 46 patients of pericardial
reverse the hemodynamic alterations.1,2 effusion. Amongst these, they documented 12 cases of
tuberculous pericarditis, nine were Indo-Asian and
Investigations three were of Afro-carribean origin. Fever, night sweats
and weight loss were common among these patients.
 Blood: Total leukocyte count is usually normal with Pulsus paradoxus was the most important sign (100%)
lymphocyte predominance. Absoute lymphocyte for the presence of echocardiographic features of
count is raised, erythrocyte sedimentation rate tamponade. According to them pericardiocentesis
(ESR) is raised. remains an effective measure for immediate relief of
 X-ray: Chest shows enlarged cardiac shadow. In symptoms of cardiac tamponade.
massive effusion, heart looks funnel shaped. The
Reuter et al9 have stressed on laboratory tests for
contours due to chambers and blood vessels are diagnosing tuberculous pericarditis. Definitive
lost. One can assess the thickness of pericardium diagnosis of tuberculous pericarditis requires isolation
by injecting air in pericardial cavity after aspirating of the tubercle bacillus from pericardial fluid, but
some fluid (which results in hydropneumo- isolating the organism is difficult. The authors studied
pericardium). 233 consecutive cases of pericardial effusion who
 MRI: Hayashi et al3 reported a patient in when underwent a predetermined diagnostic work-up. This
gadolinium enhanced magnetic resonance imaging included (i) Clinical examination (ii) pericardial fluid
(MRI) provided useful information. The incidence tests: Biochemistry; microbiology, cytology, differential
of tuberculous pericarditis has decreased but white blood cell (WBC) counts, gamma-interferon
early diagnosis and treatment are critical because (IFN-g), adenosine deaminase (ADA) levels, polymerase
constrictive pericarditis is a serious complication chain reaction (PCR) testing for mycobacterium
which has a poor prognosis.4 MRI has recently tuberculosis (iii) HIV (iv) sputum smear and culture (v)
been used to evaluate suspected pericardial heart blood biochemistry and (vi) differential WBC count.

372 Indian Journal of Clinical Practice, Vol. 22, No. 8, January 2012
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These results showed that fever, night sweets, weight (10 transudative ascites, 8 pyopericardium) effusions
loss, serum globulin (>40 g/l) and peripheral blood evaluated PCR, ADA activity and absolute lymphocyte
leukocyte count (<10 x 109/l) were independently count (ALC). Their results showed that fluid PCR for
predictive. Pericardial fluid IFN-g ≥50 pg/ml M. tuberculosis was positive in 74% of tuberculous
concentration, had 92% sensitivity, 100% specificity and effusions, where as it was falsely positive in 13% of
a positive predictive value (PPV) of 100% for diagnosis the nontuberculous group. The mean fluid ADA and
of tuberculous pericarditis. Pericardial fluid ADA ALC values were significantly higher in tuberculous
≥40 U/l had 87% sensitivity and 89% specificity. effusions than in nontuberculous effusions (p < 0.001).
A diagnositic model including pericardial ADA, The sensitivity and specificity of PCR, ADA and ALC
lymphocytic/neurtophic ratio, peripheral leukocyte were 74% and 88%, 81% and 75%, and 90% and 83%,
count and HIV status had 96% sensitivity and 97% respectively in diagnosing tuberculous effusions. They
specificity; substituting pericardial IFN-g for ADA concluded that fluid PCR should not be relied on as a
yielded 98% sensitivity and 100% specificity. They single test; rather, combined analysis with ADA or ALC
concluded that pericardial IFN-g is the most useful could be more useful in the diagnosis of tuberculous
diagnostic test. Alternatively they propose a prediction effusions in children.
model that incorporates ADA and differential WBC
counts Diagnosis
Burgess et al10 have stressed that traditional diagnostic The diagnosis is confirmed by history of low-grade
tests for tuberculous pericarditis are insensitive and fever, malaise, loss of appetite, loss of weight, cough,
often require long culture periods. Hence, newer tools dyspnea and clinical signs of pericardial effusion.
such as pericardial ADA and IFN-a were investigated by X-ray chest, EKG and 2D-echo confirm the diagnosis
Burgess et al and they concluded that pericardial fluid of pericardial effusion. Examination of pericardial
levels of ADA and IFN-a are useful in the diagnosis of fluid would differentiate the other etiological causes
tuberculous pericarditis. of pericardial effusion. One should rule out viral,
Mathur et al11 carried out study on 120 cases of serosal rheumatic, purulent and collagen disorders as causes
effusion (50 pleural, 50 peritoneal and 20 cases of of pericarditis. For confirmation of tuberculous
aetiology, one should do culture of M. tuberculosis, do
pericardial effusion). ADA was found significantly
pericardial fluid PCR, estimate ADA and IFN-g levels in
raised with a mean value of 100 U/l, 92 U/l and
pericardial fluid. Raised ESR, elevated absolute
90 U/l in tubercular pleural, peritoneal and pericardial
lymphocyte count, lymphocytic exudative nature of
effusion respectively with overall 100% sensitivity and
pericardial fluid, fluid PCR for M. tuberculosis, elevated
94.6%, specificity and cut-off value of 40 U/l.
ADA and IFN-a or g help in confirming the tuberculous
Cherian12 in his review article has suggested the etiology of pericardial fluid.
following criteria for diagnosis of tuberculous etiology
of pericardial effusion: Treatment
 Culture of Mycobacterium tuberculosis from
Antituberculous treatment with primary four drugs
pericardial fluid or tissue
(rifampicin, isoniazid, pyrizinamide and ethambutol)
 Pericardial tuberculous granuloma with acid-fast is given for first two months. Later pyrizinamide is
bacilli omitted and the remaining three drugs are given. Total
 Pericardial tuberculous granuloma + positive 9-12 months of treatment is recommended with periodic
tuberculin skin test follow-up of symptoms and signs of pericardial effusion,
 Tuberculous granuloma in scalene node or ESR, X-ray chest, ECG and 2D-echo till the complete
peripheral lymph node or pleura with positive disappearance of fluid and other clinical features.2
tuberculin test. Strang et al14 in their 10-year follow-up concluded that
 Active tuberculosis elsewhere in the body in the absence of specific contraindication, corticosteroid
 Mediastinal lymph nodes (matted with central should be prescribed in addition to antituberculous
necrosis) on CT chest/abdomen chemotherapy in the treatment of tuberculous pericardial
effusion. The ability of prednisolone to prevent
 Response to specific antitubular therapy.
complication of constrictive pericarditis and thus
Mishra et al13 in their study of 31 tuberculous (20 pleural, reduce the need for pericardiectomy is important.
8 ascites and 3 pericardial) and 24 nontuberculous Standard treatment for pericardial effusion is

Indian Journal of Clinical Practice, Vol. 22, No. 8, January 2012 373
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pericardiocentesis which is safe, especially under echo workers recommend a trial of medical therapy and
guidance. However, open drainage on admission, in their surgery in those who do not respond after six months
experience, proved to be more effective and it virtually medical therapy.
eliminated the need for repeat pericardiocentesis. Reuter et al20 in their study of 57 patients of tuberculous
According to Wragg and Strang,15
tuberculous pericarditis with adjunctive corticosteroids concluded
pericarditis is increasing in sub-Saharan Africa where that intrapericardial and oral corticosteroids were well-
tuberculosis is the most common opportunistic infection tolerated but did not improve the clinical outcome.
complicating HIV infection. Adjunctive prednisolone In their experience, standard 4-drug treatment for
is beneficial in HIV seronegative patients with TB six months was effective even in HIV-positive patients.
pericardial effusion, reducing the risk of recurrent They could not demonstrate, in their 3-year study, the
tamponade, death from pericarditis and constriction.16 significant benefits from adjunctive corticosteroids in
Benefit from similar treatment in HIV seropositive tuberculous pericarditis.
patient is encouraging, particularly where the absence of
antiretroviral drugs worsens the prognosis. Adjunctive Conclusion
prednisolone in Hakim’s study17 resulted in significant
Tuberculosis is an important etiological cause of
improvement in clinical condition and faster resolution
pericardial effusion in Afro-Asian countries. Now with
of physical signs of pericardial effusion.
spread of HIV infection, the incidence of tuberculous
Trautner and Darouiche18 reported their experience pericardial effusion has increased not only in Afro-
of 10 cases of tuberculous pericarditis. They addressed Asian countries but also all over the world. Improved
four specific topics: (1) The importance of tissue for techniques for recovery of M. tuberculosis, the use of
diagnosis (2) The optimal surgical management; (3) PCR technology, ADA levels, pericardial IFN-g, absolute
The role of corticosteroids and (4) The impact of HIV lymphocyte count, detection of mediastinal lymphnodes
infection on the management of the disease. They on CT and more clearly defined observations on
concluded from their experience of 10 cases and review 2D-echo have improved the percentage of proper
of literature that the optimal management should diagnosis. For management, apart from antibuberculous
include an open pericardial window with biopsy regime, pericardial parocentosis or open drainage
both for the diagnosis and to prevent reaccumulation and corticosteroids (oral and/or intrapericardial) have
of fluid. Corticosteroids offer benefit in preventing improved the morbidity, mortality and reduced the
fluid reaccumulation and preventing development of sequalae of constrictive pericarditis.
constrictive pericarditis. Patients with HIV seropositive
also had an excellent response to open drainage, References
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Cont’d on page 415...

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