(1)
Cardiology Department, Maria Vittoria Hospital and Department of Public Health and Pediatrics University of Torino, Torino, Italy
10.1 Bacterial Pericarditis
Bacterial pericarditis is a relatively uncommon cause of pericarditis in adults (no more than 5 % of all unselected cases) if tuberculosis is not endemic [1, 2].
In clinical practice, there are two main forms to consider:
1.
Tuberculous pericarditis
2.
Purulent pericarditis
Tuberculous Pericarditis
Tuberculous pericarditis represents a secondary localization of tuberculosis having a primary infection in a different organ (generally a previous or concomitant pleura-pulmonary involvement).
The clinical presentation may be acute pericarditis with pericardial effusion, apparently isolated effusion, effusive-constrictive pericarditis or simple constrictive pericarditis.
The diagnosis is important since the mortality rate may be as high as 20–40 % at 6 months after diagnosis and there is a specific treatment to offer [3].
Diagnosis
A definite diagnosis of tuberculous pericarditis is based on the demonstration of the presence of tubercle bacilli in the pericardial fluid or tissue. However, a probable diagnosis of tuberculous pericarditis can be achieved with evidence of the disease elsewhere (e.g. pulmonary tuberculosis) and concomitant pericarditis, a lymphocytic pericardial exudate with elevated unstimulated interferon-gamma (uIFN-γ), adenosine deaminase (ADA) or lysozyme levels. An ex juvantibus diagnosis is admitted only in countries with a high prevalence of tuberculosis with the demonstration of the response to empiric antituberculous therapy (Table 10.1) [3, 4].
Table 10.1
Diagnostic testing for the evaluation of suspected tuberculous pericarditis and pericardial effusion. Modified from 2015 ESC guidelines [3]
1. Initial non-invasive evaluation | Chest x-ray: evidence of pulmonary tuberculosis in 30 % of cases |
Echocardiogram: moderate to large pericardial effusion with frond-like projections, and thick “porridge-like” fluid (suggestive findings but not specific) | |
Chest CT scan: pericardial effusion and thickening (>3 mm), typical mediastinal and tracheobronchial lymphadenopathy (>10 mm, hypodense centres, matting), with sparing of hilar lymph nodes | |
Culture of sputum, gastric aspirate and/or urine for Mycobacterium tuberculosis | |
Scalene lymph node biopsy: if pericardial fluid is not accessible and lymphadenopathy present | |
Tuberculin skin test/QuantiFERON for TB: limited diagnostic value (only confirm previous contact, valuable in immunocompetent to exclude but not to confirm the diagnosis) | |
2. Pericardiocentesis | Therapeutic pericardiocentesis: cardiac tamponade |
Diagnostic pericardiocentesis: all patients with suspected tuberculous pericarditis and moderate to large pericardial effusions. What to look for in pericardial fluid? 1. Culture for M. tuberculosis 2. Quantitative polymerase chain reaction (Xpert MTB/RIF) testing for nucleic acids of M. tuberculosis 3. Biochemical tests to distinguish between an exudate and a transudate (fluid and serum protein; fluid and serum LDH) 4. White cell analysis and count, and cytology: a lymphocytic exudate favours tuberculous pericarditis 5. Indirect tests for tuberculous infection: interferon-gamma (IFN-γ), adenosine deaminase (ADA) or lysozyme assay | |
3. Pericardial biopsy | Therapeutic” biopsy: as part of surgical drainage in patients with cardiac tamponade or relapsing effusions after pericardiocentesis or requiring open drainage of pericardial fluid |
Diagnostic biopsy: a diagnostic biopsy is recommended in patients with >3 weeks of illness and without aetiologic (areas with a low prevalence of tuberculosis) | |
4. Empiric antituberculosis therapy | Trial of empiric antituberculosis chemotherapy is recommended for exudative pericardial effusion, after excluding other causes in areas with a high prevalence of tuberculosis |
In endemic areas with poor resources, a score has been proposed:
Tuberculous pericarditis is highly suspected if score ≥6 based on the following criteria: fever (1 point), night sweats (1 point), weight loss (2 points), globulin level >40 g/l (3 points) and peripheral leucocyte count <10 × 109/l (3 points).
Medical Therapy
A regimen consisting of rifampicin, isoniazid, pyrazinamide and ethambutol for at least 2 months, followed by isoniazid and rifampicin (total of 6 months of therapy) is effective in treating extrapulmonary tuberculosis. Treatment for 9 months or longer gives no better results and has the disadvantages of increased cost and increased risk of poor compliance [3, 4].
Prognosis
High mortality if untreated. Tuberculous pericarditis has a high risk of evolving in constrictive pericarditis, usually within 6 months in effusive forms. Prompt antibiotic therapy is essential to prevent this progression that occurs from 20 % (especially developed countries) but up to 40 % of cases. Additional treatments that may be useful to prevent constriction include (1) intrapericardial urokinase and (2) adjunctive prednisolone for 6 weeks which may halve this complication (to be avoided in HIV-infected patients since it may increase the risk of HIV-associated malignancies) [5].
Pericardiectomy is recommended if the patient’s condition is not improving or is deteriorating after 4–8 weeks of antituberculosis therapy (Recommendation class I, LOE C) [3].
Purulent Pericarditis
In developed countries, nowadays, purulent pericarditis is rare, less than 1 % of cases, and generally manifested as a serious febrile disease (fever >38 °C) with moderate to large pericardial effusions. If purulent pericarditis is suspected, urgent pericardiocentesis is mandatory for diagnosis and therapy. Blood cultures should be performed in any patients with fever >38 °C and pericarditis with or without pericardial effusion [6, 7].
Pericardial fluid is usually purulent, with low pericardial glucose and raised pericardial fluid white cell count with a high proportion of neutrophils. Fluid should be sent for bacterial, fungal and tuberculous studies.
Medical Therapy
Intravenous antimicrobial therapy should be started empirically until microbiological results are available. Pericardial drainage is crucial. Purulent effusions are often heavily loculated and likely to re-accumulate rapidly. Intrapericardial thrombolysis is a possible treatment for cases with loculated effusions in order to achieve an adequate drainage before resorting to surgery. Subxiphoid pericardiostomy and rinsing of the pericardial cavity should be considered [3, 6, 7].
10.2 Pericarditis in Renal Failure
Pericardial diseases in renal failure have become less common than in the past but should be considered in the differential diagnoses for pericarditis and pericardial effusion.
There are three main presentations of pericarditis in renal failure: (1) uremic pericarditis, occurring before renal replacement therapy or within 8 weeks from its initiation and related to retention of toxic metabolites; (2) dialysis pericarditis, occurring on dialysis (usually ≥8 weeks after its initiation); and (3) “constrictive pericarditis”, only rarely [3, 8–10].
Typical features of these forms of pericarditis include:
1.
Age and Gender Issues in the Management of Pericardial Diseases
Guidelines on the Management of Pericardial Diseases
Constrictive Pericarditis
Recurrent Pericarditis
Pericarditis Associated with Myocardial Involvement (Myopericarditis/Perimyocarditis)
Cardiac Catheterization and Interventional Techniques
Chest pain is less frequent (one third of patients are asymptomatic).
Related posts:
Age and Gender Issues in the Management of Pericardial Diseases
Guidelines on the Management of Pericardial Diseases
Constrictive Pericarditis
Recurrent Pericarditis
Pericarditis Associated with Myocardial Involvement (Myopericarditis/Perimyocarditis)
Cardiac Catheterization and Interventional Techniques
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