Tuberculous pericarditis laboratory tests
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Laboratory Findings
Tuberculin skin test
Patients with tuberculous pericarditis most often have a positive PPD test[1]. However immunocompromised patients such as those with HIV infection may have false negative tuberculin test[2]. In developing countries where TB is endemic, the tuberculin skin test may be of little value secondary to high prevalence of TB and BCG vaccination[3].
Pericardiocentesis
Pericardiocentesis should be performed in patients with cardiac tamponade, a large symptomaticpericardial effusion, an effusion that does not resolve with traditional treatment (NSAIDs), and an effusion that is suspected to be due to malignancy, a bacterial infection or tuberculosis. Among patients with tuberculous pericarditis, the pericardial fluid is blood-stained in approximately 80% of patients[4]. Tuberculous pericardial fluid is often exudative with high protein, LDH and leukocyte levels[5]. This fluid can be used to test for the presence of acid-fast bacilli which may be detected in up to approximately 40% of patients with tuberculous pericarditis[6]. Culturing the sample may increase the bacterial yield. If pericardiocentesis is not diagnostic, a pericardial biopsy may be performed. However, less invasive studies such as sputum examination, gastric washings, urine culture, and right scalene lymph node biopsy may be tried before biopsy.
- Polymerase chain reaction(PCR) is another test that helps in detecting presence of DNA of Mycobacterium tuberculosis[7][8][9]. However PCR is found to have low sensitivity and high false positive results in detection of mycobacterium in pericardial fluid[9][10][11].
- Adenosine deaminase(ADA) is an enzyme produced by leukocytes. Measurement of ADA levels in pericardial fluid is found to be of diagnostic value in tuberculous pericardial disease[12][13]. ADA levels of ≥40units/liter in pericardial fluid has a sensitivity of 87% and specificity of 89%[10].
- Measurement of interferon-gamma in pericardial fluid is another diagnostic test with a high sensitivity and a specificity of 100%, using a cutoff level of >200pg/L (n=30)[14]. Sensitivity and specificity and positive predective value were 92%, 100% and 100% respectively in another South African series[10] in the region where the prevalence of TB is high. Further studies with a larger sample size may provide further evidence to support the routine use of this test in the diagnosis of TB pericarditis.
Pericardial biopsy
Pericardial biopsy may be associated with morbidity and prolongation of the hospital stay [15]. Sensitivity of this test in diagnosing TB ranges between 10-64%[16][17]. Therefore, a normal biopsy finding does not exclude TB. The probability of obtaining a definitive bacteriological result is greatest when pericardial fluid and biopsy specimens are examined early in the effusive stage[18][19].
References
- ↑ Rooney JJ, Crocco JA, Lyons HA (1970). "Tuberculous pericarditis". Ann Intern Med. 72 (1): 73–81. PMID 5410398.
- ↑ Cegielski JP, Lwakatare J, Dukes CS, Lema LE, Lallinger GJ, Kitinya J; et al. (1994). "Tuberculous pericarditis in Tanzanian patients with and without HIV infection". Tuber Lung Dis. 75 (6): 429–34. PMID 7718831.
- ↑ Ng TT, Strang JI, Wilkins EG (1995). "Serodiagnosis of pericardial tuberculosis". QJM. 88 (5): 317–20. PMID 7796085.
- ↑ Mayosi BM, Volmink JA, Commerford PJ. Pericardial disease: an evidence-based approach to diagnosis and treatment. In: Yusuf S, Cairns JA, Camm AJ, Fallen BJ, eds. Evidence-Based Cardiology. 2nd ed. London: BMJ Books; 2003: 735–748.
- ↑ Burgess LJ, Reuter H, Carstens ME, Taljaard JJ, Doubell AF (2002). "Cytokine production in patients with tuberculous pericarditis". Int J Tuberc Lung Dis. 6 (5): 439–46. PMID 12019920.
- ↑ Fowler NO (1991). "Tuberculous pericarditis". JAMA. 266 (1): 99–103. PMID 2046135.
- ↑ Brisson-Noël A, Gicquel B, Lecossier D, Lévy-Frébault V, Nassif X, Hance AJ (1989). "Rapid diagnosis of tuberculosis by amplification of mycobacterial DNA in clinical samples". Lancet. 2 (8671): 1069–71. PMID 2572798.
- ↑ Rana BS, Jones RA, Simpson IA (1999). "Recurrent pericardial effusion: the value of polymerase chain reaction in the diagnosis of tuberculosis". Heart. 82 (2): 246–7. PMC 1729120. PMID 10409547.
- ↑ 9.0 9.1 Cegielski JP, Devlin BH, Morris AJ, Kitinya JN, Pulipaka UP, Lema LE; et al. (1997). "Comparison of PCR, culture, and histopathology for diagnosis of tuberculous pericarditis". J Clin Microbiol. 35 (12): 3254–7. PMC 230157. PMID 9399529.
- ↑ 10.0 10.1 10.2 Reuter H, Burgess L, van Vuuren W, Doubell A (2006). "Diagnosing tuberculous pericarditis". QJM. 99 (12): 827–39. doi:10.1093/qjmed/hcl123. PMID 17121764.
- ↑ Lee JH, Lee CW, Lee SG, Yang HS, Hong MK, Kim JJ; et al. (2002). "Comparison of polymerase chain reaction with adenosine deaminase activity in pericardial fluid for the diagnosis of tuberculous pericarditis". Am J Med. 113 (6): 519–21. PMID 12427503.
- ↑ Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y; et al. (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology". Eur Heart J. 25 (7): 587–610. doi:10.1016/j.ehj.2004.02.002. PMID 15120056.
- ↑ Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
- ↑ Burgess LJ, Reuter H, Carstens ME, Taljaard JJ, Doubell AF (2002). "The use of adenosine deaminase and interferon-gamma as diagnostic tools for tuberculous pericarditis". Chest. 122 (3): 900–5. PMID 12226030.
- ↑ Reuter H, Burgess LJ, Louw VJ, Doubell AF (2007). "The management of tuberculous pericardial effusion: experience in 233 consecutive patients". Cardiovasc J S Afr. 18 (1): 20–5. PMID 17392991.
- ↑ Komsuoğlu B, Göldelï O, Kulan K, Komsuoğlu SS (1995). "The diagnostic and prognostic value of adenosine deaminase in tuberculous pericarditis". Eur Heart J. 16 (8): 1126–30. PMID 8665976.
- ↑ SCHEPERS GW (1962). "Tuberculous pericarditis". Am J Cardiol. 9: 248–76. PMID 14498251.
- ↑ BARR JF (1955). "The use of pericardial biopsy in establishing etiologic diagnosis in acute pericarditis". AMA Arch Intern Med. 96 (5): 693–6. PMID 13257965.
- ↑ Strang G, Latouf S, Commerford P, Roditi D, Duncan-Traill G, Barlow D; et al. (1991). "Bedside culture to confirm tuberculous pericarditis". Lancet. 338 (8782–8783): 1600–1. PMID 1684009.