Presentation on Tuberculous Pericardial Effusion in NIDCH, Dhaka,Bangladesh.

1. Tuberculous
Pericardial effusion
Dr Saleh Ahmed Ador
MD Phase A, Cardiology
NICVD, Dhaka.

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. Pericardial TB present as
• Acute Pericarditis
• Pericardial Effusion
• Cardiac Temponade
• Chronic Constrictive Pericarditis

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. • Pericardial effusion is an abnormal
accumulation of fluid in the pericardial cavity.
• Normal levels of pericardial fluid are from 15
to 50 ml

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. Symptoms
• Low grade fever
• Malaise
• Night sweats
• Cough
• Weight loss
• Retrosternal discomfort
• Palpitation
• Breathlessness on exertion or even at rest
• Orthopnoea

8. Examination
General Examination:
• Fever
• Pulse – low volume, trachycardia, pulsus
paradoxus may be present
• Hypotension
• JVP- raised, kussmaul’s sign positive

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. 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. 2. Chest X ray lateral view
A vertical opaque
line separating a vertical
lucent line directly behind the
sternum (Oreo cookie sign)

12. 3. ECG
• Low voltage ECG
• Tachycardia
• Electrical alternans
• T inversion

13. Electrical altrnans
Low voltage ECG

14. 4. Echocardiography:
Presence of echo
free space between
epicardium and
paricardium

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. 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. 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. 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. • Dose- Tab Prednisolone
• 60mg/day for 4 weeks
• 30mg/day for 4 weeks
• 15mg/day for 2 weeks
• 5mg/day for 1 week

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. Complications
• Constrictive pericarditis
• Cardiac temponade
• Chronic heart failure
• Recurrent pericarditis
• Bacterial infection

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. 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. • 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