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Interesting Case Rounds

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

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Interesting Case Rounds

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  1. Interesting Case Rounds Nicole Kirkpatrick February 7, 2008

  2. Case • 25 y.o. first nations male • CC: RUQ pain and SOB

  3. 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

  4. HPI • PMH - healthy • PSH - none • Medications - none • Allergies - none • Smoker • ETOH -15 beers/w • Marijuana use

  5. Vital signs • HR 105 • BP 110/80 • RR 25 • T 38 • SpO2 98% on R/A

  6. 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

  7. Investigations?

  8. Investigations • Blood work • Hb normal • WBC slightly elevated • Normal electrolytes • Normal renal function • ALT slightly elevated

  9. Investigations • ECG • Sinus tachycardia • Low voltage

  10. Investigations • CXR

  11. Chest X-ray

  12. Thoughts?

  13. 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

  14. Initial management

  15. Management • Transferred to larger centre for definitive diagnosis • ECHO • Pericardiocentesis • Pericardial biopsy

  16. Diagnosis • Tuberculous pericarditis

  17. Objectives • Review TB • Epidemiology • Presentations • TB pericarditis • Epidemiology • Presentation • Diagnosis • Treatment

  18. Mycobacterium tuberculosis

  19. Tuberculosis • Mycobacterium tuberculosis • Aerobic, non-spore forming, slow growing bacillus • Humans are the only reservoir • Other Mycobacterium spp.

  20. World Incidence of TB Incidence per 100,000 pop / year > 300 100 - 299 50 - 99 25 - 49 < 24 No data Source: 2005 WHO (maps.maplecroft.com)

  21. 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

  22. Tuberculosis and HIV • Increased risk of: • Primary disease becoming active infection • Reactivation • 5-10% per year • Extrapulmonary TB

  23. WHO Estimates of TB (2005) • Incidence: 8.8 million worldwide • Canada • 5 cases / 100,000 (1616 total) • Prevalence: 14 million

  24. 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

  25. Tuberculous Pericarditis • Pericardium involved via • Retrograde lymphatic spread • Peritracheal, peribronchial, mediastinal LN • Contiguous spread from adjacent lesion • Lung, pleurae, ribs, diaphragm, peritoneum • Hematogenous spread

  26. 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

  27. Tuberculous Pericarditis • Mortality • 80-90% in pre-antibiotic era • 8-17% in HIV negative patients • 17-34% in HIV positive patients

  28. Tuberculous Pericarditis • Three clinical presentations • Pericardial effusion (80%) • Constrictive pericarditis (5%) • 30-60% of patients progress to constrictive pericarditis • Effusion-constriction (15%)

  29. 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

  30. Symptoms Cough Dyspnea CP Night sweats Orthopnea Weight loss Signs Tachycardia Fever JVD HSM Ascites Edema Tuberculous Pericarditis

  31. 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

  32. 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

  33. 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

  34. 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

  35. Diagnosis • Tuberculin Skin Test • Can be negative in up to 30% due to anergy

  36. 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

  37. Diagnosis • Pericardial biopsy • Stain tissue for AFB • Histology • Granulomatous inflammation

  38. 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

  39. 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

  40. Treatment • Steroids • Still controversial • Decrease mortality, need for pericardiectomy

  41. Treatment • Pericardiectomy • After initiation of anti-tuberculous treatment

  42. 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

  43. Questions or Comments?

  44. References • Cherian, G. (2004). "Diagnosis of tuberculous aetiology in pericardial effusions." Postgrad Med J80(943): 262-6. • Mayosi, B. M., L. J. Burgess, et al. (2005). "Tuberculous pericarditis." Circulation112(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 Dis6: 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 Med351(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." Qjm97(8): 525-35. • Syed, F. F. and B. M. Mayosi (2007). "A modern approach to tuberculous pericarditis." Prog Cardiovasc Dis50(3): 218-36. • Wragg, A. and J. I. Strang (2000). "Tuberculous pericarditis and HIV infection." Heart84(2): 127-8. • UpToDate • eMedicine

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