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.
Approach to patients with suspected tuberculous pericarditis[1]
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- Initial evaluation
- Chest radiograph may reveal changes suggestive of pulmonary tuberculosis in 30% of cases.
- Echocardiogram: the presence of a large pericardial effusion with frond-like projections, and thick "porridge-like" exudate is suggestive of an exudate but not specific for a tuberculous etiology.
- CT scan and/or MRI of the chest are alternative imaging modalities where available: for evidence of pericardial effusion and thickening (>5 mm) and typical mediastinal and tracheobronchial lymphadenopathy (>10 mm, hypodense centers, matting), with sparing of hilar lymph nodes.
- Culture of sputum, gastric aspirate, and/or urine should be considered in all patients.
- Right scalene lymph node biopsy if pericardial fluid is not accessible and lymphadenopathy is present.
- Tuberculin skin test is not helpful regardless of the background prevalence of tuberculosis.5,50
- Pericardiocentesis
- Therapeutic pericardiocentesis is indicated in the presence of cardiac tamponade.
- Diagnostic pericardiocentesis should be considered in all patients with suspected tuberculous pericarditis, and the following tests should be performed:
- Direct inoculation of the pericardial fluid into double-strength liquid Kirchner culture medium at the bedside and culture for M tuberculosis.
- Biochemical tests to distinguish between an exudate and a transudate (fluid and serum protein; fluid and serum LDH).
- Indirect tests for tuberculous infection: ADA, IFN-, or lysozyme assay.
- Pericardial biopsy
- "Therapeutic" biopsy: as part of surgical drainage in patients with severe tamponade relapsing after pericardiocentesis.
- Diagnostic biopsy: in areas in which TB is endemic, a diagnostic biopsy is not required before commencing empirical antituberculosis treatment. In areas in which TB is not endemic, a diagnostic biopsy is recommended in patients with >3 weeks of illness and without etiologic diagnosis having been reached by other tests.3
- Empirical antituberculosis chemotherapy
- Tuberculosis endemic in the population: trial of empirical antituberculous chemotherapy is recommended for exudative pericardial effusion, after other causes such as malignancy, uremia, and trauma have been excluded.
- Tuberculosis not endemic in the population: when systematic investigation fails to yield a diagnosis of tuberculous pericarditis, there is no justification for starting antituberculosis treatment empirically.
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References
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