Spare no organ: a curious case of tuberculous pericarditis

SESSION TITLE: Lung Pathology Case Report Posters 5 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Tuberculous pericarditis is a rare and life-threatening complication of tuberculosis, primarily in areas of Africa and East Asia1. Mycobacterium tuberculosis (MTB) infects the pericardium causing inflammation and fluid accumulation. Mortality rates can reach up to 40%, even in non-endemic regions such as Northern America1. This case presents a patient who developed tuberculous pericarditis despite receiving appropriate anti-tuberculosis treatment. CASE PRESENTATION: A 39-year-old male who immigrated from mainland China presented to our Emergency Department with shortness of breath, cough, palpitations, and chest pain that worsened with leaning forward. He was recently diagnosed with active pulmonary tuberculosis in the setting of negative HIV status, and started anti-tuberculosis treatment. Physical examination revealed tachycardia, and bilateral rhonchi. A transthoracic echocardiogram revealed normal ventricular ejection, mild concentric ventricular hypertrophy, and a small left ventricular cavity. CT-chest showed bilateral pulmonary cavitations, thickened pleura with bilateral effusions, along with rib and vertebral fractures; consistent with hematogenous spread of MTB.The patient was treated with rifampin, isoniazid, pyridoxine, and ethambutol. Hospital course was complicated by persistent sinus tachycardia despite appropriate fluid resuscitation and antibiotic therapy, eventually requiring metoprolol for rate control. A diagnosis of tuberculous pericarditis was made based on clinical findings only, as he exhibited no EKG changes consistent with pericarditis, and no pericardial effusion. The patient was given corticosteroids, resulting in significant improvement in his symptoms. DISCUSSION: Tuberculous pericarditis is a severe form of extrapulmonary tuberculosis that can be difficult to diagnose due to its nonspecific symptoms and imaging findings. Signs and symptoms include chest pain, shortness of breath, cough, and sinus tachycardia1. The gold standard of diagnosis for tuberculous pericarditis is the detection of MTB in pericardial fluid by acid-fast bacilli smear/culture2. However, a presumptive diagnosis can be made based on clinical and imaging findings. Treatment of tuberculous pericarditis consists of RIPE therapy and corticosteroids. If left untreated, tuberculous pericarditis can progress to constrictive pericarditis, and is associated with increased mortality up to 40%1,3. The role of corticosteroids in patients with tuberculous pericarditis, particularly those who are HIV-positive, remains controversial. Some studies show that corticosteroids may help prevent constrictive pericarditis, while other studies demonstrate no significant effect of adjunctive corticosteroids on mortality, cardiac tamponade, or the development of constrictive pericarditis².Our case described a patient with pulmonary tuberculosis, Pott's Disease and clinical symptoms of pericarditis were present in the absence of characteristic EKG changes or pericardial effusion. Although there was no definitive diagnosis of tuberculous pericarditis, a strong clinical suspicion triggered prompt treatment with corticosteroids in addition to anti-tuberculosis regimen. CONCLUSIONS: Tuberculosis pericarditis is a rare but potentially life-threatening complication of tuberculosis. A high index of suspicion is necessary for early diagnosis and prompt initiation of anti-tuberculosis therapy and corticosteroids. The case presented here highlights the importance of considering tuberculosis pericarditis as a potential diagnosis in patients with a history of tuberculosis who present with unexplained chest pain and tachycardia despite appropriate treatment. REFERENCE #1: Lopez-Lopez, J. P., Posada-Martinez, E. L., Saldarriaga, C., Wyss, F., Ponte-NEgretti, C. I., Alexander, B., & Miranda-Arboleda, A. F. (2021, April 6). Tuberculosis and the Heart. Journal of the American Heart Association, 10(7), 1-8. E019435–e019435 REFERENCE #2: Bongani, M., Mpiko, M., Bosch, N., Shaheen, J., & Hyeujung, P. (2014, September 14). Prednisolone and Mycobacterium indicus pranii in Tuberculous Pericarditis. The New England Journal of Medicine, 371(12), 1121-1130. 10.1056/NEJMoa1407380 REFERENCE #3: Mayosi, B. M., Burgess, L. J., & Doubell, A. F. (2005, December 6). Tuberculosis Pericarditis. Circulation, 112(23), 3608-3616. https://doi.org/10.1161/CIRCULATIONAHA.105.543066 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Sindhuri Gollamudi No relevant relationships by Wael Kalaji No relevant relationships by Olga Knap No relevant relationships by Nabil Mesiha No relevant relationships by Steven Miller No relevant relationships by Kunal Nangrani No relevant relationships by Vagdevi Seetamraju No relevant relationships by Anuj Shivalingaiah No relevant relationships by Seungmo Suh No relevant relationships by Viswanath Vasudevan No relevant relationships by Kiran Zaman