Tuberculous pericarditis with and without HIV

Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms

Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.

Tuberculous Pericarditis in Childhood: A Case Report and a Systematic Literature Review

Tuberculous pericarditis (TBP) is an important cause of pericarditis worldwide while being infrequent in childhood, especially in low-TB-incidence countries. We report a case of TBP and provide a systematic review of the literature, conducted by searching PubMed, Scopus, and Cochrane to find cases of TBP in pediatric age published in the English language between the year 1990 and the time of the search. Of the 587 search results obtained, after screening and a backward citation search, 45 studies were selected to be included in this review, accounting for a total of 125 patients. The main signs and symptoms were fever, cough, weight loss, hepatomegaly, dyspnea, and increased jugular venous pressure or jugular vein turgor. A definitive diagnosis of TBP was made in 36 patients, either thanks to microbiological investigations, histological analysis, or both. First-line antitubercular treatment (ATT) was administered in nearly all cases, and 69 children underwent surgical procedures. Only six patients died, and only two died of TBP. TBP in childhood is relatively uncommon, even in high-TB-prevalence countries. Clinical manifestations, often suggestive of right-sided cardiac failure, are subtle, and diagnosis is challenging. TBP has an excellent prognosis in childhood; however, in a significant proportion of cases, invasive surgical procedures are necessary.

Hemopericardium: A Comprehensive Clinical Review of Etiology and Diagnosis

Hemorrhagic pericardial effusion (HPE) is a subtype of pericardial effusion marked by the accumulation of serosanguineous or bloody fluid within the pericardial cavity. We present a case of a 65-year-old female who presented to the hospital with abdominal pain and was found to have pericardial effusion. The patient's condition evolved into cardiac tamponade, and employing diagnostic techniques such as imaging and pericardiocentesis, a substantial bloody effusion was uncovered, indicative of HPE. This report underscores the complexity of HPE diagnosis and examines the non-iatrogenic etiological factors contributing to HPE, focusing on three primary causes: malignancy, infection, and autoimmune disorders. It offers a detailed exploration of each etiology, backed by current medical literature and case studies. It outlines the diagnostic strategies pertinent to each cause, underscoring the need for a tailored approach to manage such cases. It emphasizes the importance of a meticulous and individualized diagnostic process, vital for accurate identification and effective management of this condition.

[Extrapulmonary tuberculosis]

Extrapulmonary tuberculosis (TB) presents unique diagnostic and therapeutic challenges. The site of involvement can vary widely, with common sites including the lymph nodes, pleura, skin, ear, nose and throat, genitourinary system, pericardium, gastrointestinal tract, bones and joints, and central nervous system. Clinical manifestations of extrapulmonary TB are diverse and often non-specific. Diagnosis is based on a combination of clinical suspicion, imaging, histopathology, and microbiology. Treatment of extrapulmonary TB generally follows similar principles to pulmonary TB, but the duration of treatment depends on the site of involvement and the extent of the disease. Increased awareness among healthcare providers is essential for the timely recognition and effective management of extrapulmonary TB cases.

Pericardial Disease in the Developing World

Pericardial disease in the developing world is dominated primarily by effusive and constrictive syndromes and contributes to the acute and chronic heart failure burden in many regions. The confluence of geography (location in the tropics), a significant burden of diseases of poverty and neglect, and a significant contribution of communicable diseases to the general burden of disease is reflected in the wide etiological spectrum of causes of pericardial disease. The prevalence of Mycobacterium tuberculosis in particular, is high throughout much of the developing world where it is the most frequent and important cause of pericarditis and is associated with significant morbidity and mortality. Acute viral/idiopathic pericarditis, which is the primary manifestation of pericardial disease in the developed world is believed to occur significantly less frequently in the developing world. Although diagnostic approaches and criteria to establish the diagnosis of pericardial disease are similar throughout the globe, resource constraints such as access to multimodality imaging and hemodynamic assessment are a major limitation in much of the developing world. These important considerations significantly influence the diagnostic and treatment approaches, and outcomes related to pericardial disease.

Serosal membrane tuberculosis in Iran: A comprehensive review of evidences

Tuberculosis (TB) is among the most common cause of serositis. There are many uncertainties in diagnostic and therapeutic approach to serous membranes tuberculosis. Our aim in the present review is to discuss the regional facilities for timely diagnosis, rapid decision-making and appropriate treatment regarding to serous membranes tuberculosis; with emphasis on situation in Iran. A comprehensive literature searches about the status of serous membranes tuberculosis in Iran were performed in English databases including Google Scholar, Science Direct, Scopus, Pub Med, and Web of Sciences, Persian SID databases, between 2000 and 2021. The main findings of the present review are as follow: a) pleural tuberculosis is more common than pericardial or peritoneal tuberculosis. b) Clinical manifestations are non-specific and so non-diagnostic. c) Smear and culture, PCR and characteristic granulomatous reaction have been used for definitive TB diagnosis by physicians. d) With Adenosine Deaminase Assays and Interferon-Gamma Release Assays in mononuclear dominant fluid, a possible diagnosis of TB is proposed by experienced physicians in Iran. e) In area of endemic for tuberculosis including Iran, a possible diagnosis of TB is enough to begin empirical treatment. f) In patients with uncomplicated tuberculosis serositis, treatment is similar to pulmonary tuberculosis. First line drugs are prescribed unless evidence of MDR-TB is detected. g) The prevalence of drug resistant tuberculosis (MDR-TB) in Iran is between 1% and 6%, and are treated by empirical standardized treatment. h) It is not known whether adjuvant corticosteroids are effective in preventing long term complication. i) Surgery may be recommended for MDR-TB. Tamponade or constrictive pericarditis and intestinal obstruction. In conclusion, it is recommended to consider serosal tuberculosis in patients who have unknown mononuclear dominant effusion and prolonged constitutional symptoms. Experimental treatment with first line anti-TB drugs can be started based on possible diagnostic findings.

Partial pericardiectomy for refractory acute tuberculous pericarditis: A case report

INTRODUCTION

Tuberculosis is an infectious disease that usually manifests in the lungs but can also affect other organs, including the cardiovascular system. In this article, we present a rare case of purulent pericarditis caused by Mycobacterium tuberculosis.

PRESENTATION OF CASE

A 67-year-old man was admitted to the emergency department with a large pericardial effusion with evidence of cardiac tamponade caused by acute pericarditis. The patient underwent surgical pericardial drainage, and a total volume of 500 mL of purulent fluid was collected with a positive culture for Mycobacterium tuberculosis. Despite antituberculous drugs, the patient presented with clinical worsening and recurrence of large pericardial effusion. Therefore, he was submitted to a second intervention by full median sternotomy to drain the pericardial effusion and perform a surgical pericardial debridement associated with a partial pericardiectomy. After the procedure, he improved clinically and was discharged after 24 days of hospitalization.

DISCUSSION

Pericardiectomy is recommended for patients with refractory tuberculous pericarditis after four to eight weeks of antituberculous treatment. We decided not to wait that long to perform an open surgical partial pericardiectomy and debridement with a median sternotomy approach. We believe that this more aggressive surgical approach would be more efficient to combat the infection, which was causing progressive deterioration of patient's clinical condition and early recurrence of significant pericardial effusion.

CONCLUSION

Open partial pericardiectomy with surgical debridement could be an efficient approach for treatment of a refractory acute tuberculous pericarditis.

Multimodality Imaging in HIV-Associated Cardiovascular Complications: A Comprehensive Review

Human immunodeficiency virus (HIV) infection is a leading cause of mortality and morbidity worldwide. The introduction of antiretroviral therapy (ART) has significantly reduced the risk of developing acquired immune deficiency syndrome and increased life expectancy, approaching that of the general population. However, people living with HIV have a substantially increased risk of cardiovascular diseases despite long-term viral suppression using ART. HIV-associated cardiovascular complications encompass a broad spectrum of diseases that involve the myocardium, pericardium, coronary arteries, valves, and systemic and pulmonary vasculature. Traditional risk stratification tools do not accurately predict cardiovascular risk in this population. Multimodality imaging plays an essential role in the evaluation of various HIV-related cardiovascular complications. Here, we emphasize the role of multimodality imaging in establishing the diagnosis and aetiopathogenesis of various cardiovascular manifestations related to chronic HIV disease. This review also provides a critical appraisal of contemporary data and illustrative cases.

Cardiovascular Involvement in Tuberculosis: From Pathophysiology to Diagnosis and Complications-A Narrative Review

Although primarily a lung disease, extra-pulmonary tuberculosis (TB) can affect any organ or system. Of these, cardiovascular complications associated with disease or drug toxicity significantly worsen the prognosis. Approximately 60% of patients with TB have a cardiovascular disease, the most common associated pathological entities being pericarditis, myocarditis, and coronary artery disease. We searched the electronic databases PubMed, MEDLINE, and EMBASE for studies that evaluated the impact of TB on the cardiovascular system, from pathophysiological mechanisms to clinical and paraclinical diagnosis of cardiovascular involvement as well as the management of cardiotoxicity associated with antituberculosis medication. The occurrence of pericarditis in all its forms and the possibility of developing constrictive pericarditis, the association of concomitant myocarditis with severe systolic dysfunction and complication with acute heart failure phenomena, and the long-term development of aortic aneurysms with risk of complications, as well as drug-induced toxicity, pose complex additional problems in the management of patients with TB. In the era of multidisciplinarity and polymedication, evidence-based medicine provides various tools that facilitate an integrative management that allows early diagnosis and treatment of cardiac pathologies associated with TB.

Cardiovascular Disease Among Persons Living With HIV: New Insights Into Pathogenesis and Clinical Manifestations in a Global Context

Widespread use of contemporary antiretroviral therapy globally has transformed HIV disease into a chronic illness associated with excess risk for disorders of the heart and circulatory system. Current clinical care and research has focused on improving HIV-related cardiovascular disease outcomes, survival, and quality of life. In high-income countries, emphasis on prevention of atherosclerotic coronary artery disease over the past decade, including aggressive management of traditional risk factors and earlier initiation of antiretroviral therapy, has reduced risk for myocardial infarction among persons living with human immunodeficiency virus-1 infection. Still, across the globe, persons living with human immunodeficiency virus-1 infection on effective antiretroviral therapy treatment remain at increased risk for ischemic outcomes such as myocardial infarction and stroke relative to the persons without HIV. Unique features of HIV-related cardiovascular disease, in part, include the pathogenesis of coronary disease characterized by remodeling ectasia and unusual plaque morphology, the relative high proportion of type 2 myocardial infarction events, abnormalities of the aorta such as aneurysms and diffuse aortic inflammation, and HIV cerebrovasculopathy as a contributor to stroke risk. Literature over the past decade has also reflected a shift in the profile and prevalence of HIV-associated heart failure, with a reduced but persistent risk of heart failure with reduced ejection fraction and a growing risk of heart failure with preserved ejection fraction. Cardiac magnetic resonance imaging and autopsy data have emphasized the central importance of intramyocardial fibrosis for the pathogenesis of both heart failure with preserved ejection fraction and the increase in risk of sudden cardiac death. Still, more research is needed to better characterize the underlying mechanisms and clinical phenotype of HIV-associated myocardial disease in the current era. Across the different cardiovascular disease manifestations, a common pathogenic feature is that HIV-associated inflammation working through different mechanisms may amplify underlying pathology because of traditional risk and other host factors. The prevalence and phenotype of individual cardiovascular disease manifestations is ultimately influenced by the degree of injury from HIV disease combined with the profile of underlying cardiometabolic factors, both of which may differ substantially by region globally.

A Case of Pericardial Effusion and Human Immunodeficiency Virus in the Postmodern Era

Pericardial effusion is a relatively common cardiac pathology associated with various infectious and non-infectious etiologies. In developed countries, viral pericarditis and idiopathic reasons are the two most common causes of this condition. Mycobacterium tuberculosis is prevalent in developing countries and is the most common cause of pericardial effusion in these regions. Parasitic and bacterial etiologies are encountered less frequently. In this report, we describe the case of a large pericardial effusion in a patient with HIV and latent tuberculosis (TB). Pericardiocentesis and analysis of pericardial fluid did not reveal any specific etiology, indicating viral or idiopathic pericarditis as an etiology. We also present an analysis of global data related to pericardial effusion in HIV/AIDS patients, and the impact that the increasing availability of antiretroviral therapy (ART) worldwide over the last three decades had had on it. The CD4 count has been described as an essential factor for the prognosis of this condition. Patients with lower CD4 count levels would be at higher risk of severe pericardial effusion.

A case report and review of literature: Tuberculous pericarditis with pericardial effusion as the only clinical manifestation

Tuberculosis is a main cause of pericardial disease in developing countries. However, in patients with atypical clinical presentation, it can lead to misdiagnosis, missed diagnosis, and delayed treatment. In this study, we report a case of a 61-year-old woman admitted to the cardiac intensive care unit with "weakness and loss of appetite" and a large pericardial effusion shown by echocardiography. After hospitalization, a pericardiocentesis was performed, and the pericardial fluid was hemorrhagic. However, the Xpert MTB/RIF and T-SPOT tests were negative, and repeated phlegm antacid smears and culture of pericardial fluid did not reveal antacid bacilli. The patient eventually underwent thoracoscopic pericardial biopsy, which revealed extensive inflammatory cells and significant granulomas. Combined with the fact that the patient's pericardial effusion was exudate, the patient was considered to be suspected of tuberculous pericarditis (TBP) and given empirical anti-tuberculosis treatment the patient's symptoms improved and the final diagnosis was TBP. In this case report, it is further shown that a negative laboratory test cannot exclude tuberculosis infection. In recurrent unexplained pericardial effusions, the pericardial biopsy is feasible. In countries with a high burden of tuberculosis, empirical antituberculosis therapy may be used to treat the pericardial effusion that excludes other possible factors.

Descriptive Study of Pericarditis Outcomes in Different Etiologies and Risk Factors: A Retrospective Record Review

Background: Pericarditis is an inflammatory pericardial disorder that can be caused by several infectious and non-infectious illnesses. Coronavirus disease 2019 (COVID-19) was recently added to the long list of pericarditis causes. As a result, this study aims to look at the incidence of various etiologies of pericarditis, including post-COVID-19 vaccine and risk factors, at King Abdulaziz University Hospital in Jeddah, Saudi Arabia.

Methods: Between 2012 and 2022, all male and female patients diagnosed with acute, chronic, or constrictive pericarditis at the King Abdulaziz University Hospital clinic were included in this retrospective study, which took place in June 2022. Data were collected from the hospital's medical records, including the patient's demographic information, pericarditis history, medical history, social background, laboratory tests, Echocardiogram (ECHO) and electrocardiogram (ECG) readings, and medication history. Associations were tested using univariate and bivariate analysis.

Results: Acute pericarditis was diagnosed in 59 (89.1%) patients and the most common symptoms were chest pain and shortness of breath (SOB) followed by fever and cough.Idiopathic pericarditis was the primary etiology 30 (46.9%) with male predominance 25 (55.6%), followed by infections and then cardiac presenting primarily with chest pain 25 (83.3%). In comparison, the most common presentation in females was autoimmune, as seen in eight patients (42.1%). Most patients required aspirin, ibuprofen, and colchicine. Among outcomes, of a total of 64 patients, five died within 30 days. Moreover, four (7.5%) experienced subsequent cardiac tamponades, which was mainly due to malignancy (50%) (p<0.05).

Conclusion: There was a substantial relationship between malignancy and developing morbid complications, with 59 patients out of 64 getting acute pericarditis and the remainder chronic and constrictive pericarditis with idiopathic pericarditis being the leading causes.

Point-of-Care Ultrasound for Tuberculosis Management in Sub-Saharan Africa-A Balanced SWOT Analysis

Point-of-care ultrasound (POCUS) is an increasingly accessible skill, allowing for the decentralization of its use to non-specialist healthcare workers to guide routine clinical decision making. The advent of ultrasound-on-a-chip has transformed the technology into a portable mobile health device. Due to its high sensitivity to detect small consolidations, pleural effusions and sub pleural nodules, POCUS has recently been proposed as a sputum-free likely triage tool for tuberculosis (TB). To make an objective assessment of the potential and limitations of POCUS in routine TB management, we present a Strengths, Weaknesses, Opportunities & Threats (SWOT) analysis based on a review of the relevant literature and focusing on Sub-Saharan Africa (SSA). We idenitified numerous strengths and opportunities of POCUS for TB management e.g.; accessible, affordable, easy to use & maintain, expedited diagnosis, extra-pulmonary TB detection, safer pleural/pericardial puncture, use in children/pregnant women/PLHIV, targeted screening of TB contacts, monitoring TB sequelae, and creating AI decision support. Weaknesses and external threats such as operator dependency, lack of visualization of central lung pathology, poor specificity, lack of impact assessments and data from Sub-Saharan Africa must be taken into consideration to ensure that the potential of the technology can be fully realized in research as in practice.

High rate of left ventricular hypertrophy on screening echocardiography among adults living with HIV in Malawi

BACKGROUND

There are limited data on structural heart disease among people living with HIV in southern Africa, where the success of antiretroviral therapy (ART) has drastically improved life expectancy and where risk factors for cardiovascular disease are prevalent.

METHODS

We performed a cross-sectional study of screening echocardiography among adults (≥18 years) with HIV in Malawi presenting for routine ART care. We used univariable and multivariable logistic regression to evaluate correlates of abnormal echocardiogram.

RESULTS

A total of 202 individuals were enrolled with a median age of 45 years (IQR 39-52); 52% were female, and 27.7% were on antihypertensive medication. The most common clinically significant abnormality was left ventricular hypertrophy (LVH) (12.9%, n=26), and other serious structural heart lesions were rare (<2% with ejection fraction less than 40%, moderate-severe valve lesions or moderate-severe pericardial effusion). Characteristics associated with abnormal echocardiogram included older age (OR 1.04, 95% CI 1.01 to 1.08), higher body mass index (OR 1.09, 95% CI 1.02 to 1.17), higher mean systolic blood pressure (OR 1.03, 95% CI 1.02 to 1.05) and higher mean diastolic blood pressure (OR 1.03, 95% CI 1.01 to 1.05). In a multivariable model including age, duration on ART, body mass index, and systolic and diastolic blood pressure, only mean body mass index (adjusted OR 1.10, 95% CI 1.02 to 1.19), systolic blood pressure (aOR 1.05, 95% CI 1.03 to 1.08) and diastolic blood pressure (aOR 0.96, 95% CI 0.92 to 1.00) remained associated with abnormal echocardiogram.

CONCLUSIONS

LVH was common in this population of adults on ART presenting for routine care and was associated with elevated blood pressure. Further research is needed to characterise the relationship between chronic hypertension, LVH and downstream consequences, such as diastolic dysfunction and heart failure in people living with HIV.

Atrial fibrillation, end-stage renal disease and hemorrhagic pleural-pericarditis

Pericarditis is the most common pericardial disease found in clinical practice, with an incidence of acute pericarditis reported in 27.7 cases per 100,000 subjects per year. Hemodialysis in end stage renal disease (ESRD) is associated with frequent cardiovascular modifications, mostly because of the highly fluctuating levels of potassium, magnesium, ionized calcium, sodium and volume status. The risk of arrhythmias is increased and chronic atrial fibrillation (AF) can be found among approximately 14% of patients. The renal disease combined with arrhythmias increases the risk of systemic thromboembolism but also of bleeding events. Here we present the case of a male patient, with ESRD, recently diagnosed with intradialytic paroxysmal AF for which oral anticoagulation therapy is initiated, but it’s early complicated with hemorrhagic pleural-pericarditis.

The optimal duration of anti-tuberculous therapy before pericardiectomy in constrictive tuberculous pericarditis

BACKGROUND

It is unclear about the duration of anti-tuberculous therapy before pericardiectomy (DATT) in the patients with constrictive tuberculous pericarditis. This study aims to explore the optimal DATT and its impact on surgical outcomes in these patients.

METHODS

We retrospectively enrolled 93 patients with constrictive tuberculous pericarditis undergoing pericardiectomy and divided them into two groups according to the optimal cutoff value of DATT which was determined by the receiver operating characteristic (ROC) curve and Youden Index. Postoperative and survival outcomes were compared between the two groups.

RESULTS

The optimal cutoff value of DATT was 1.05 (months). The enrolled patients were divided into the DATT ≤ 1.05 group and the DATT > 1.05 group, with 24 (25.8%) and 69 (74.2%) cases, respectively. Comparing with the DATT ≤ 1.05 group, the DATT > 1.05 group had shorter postoperative ICU stay (P = 0.023), duration of chest drainage (P = 0.002), postoperative hospital stay (P = 0.001) and lower incidence of postoperative complications (P < 0.001). There were no statistical differences between the two groups in recurrence and survival outcomes.

CONCLUSIONS

It would be of potential benefit to enhance recovery after pericardiectomy if DATT lasted for at least 1 month in the patients with constrictive tuberculous pericarditis.

Diagnostic accuracy of the Xpert MTB/RIF assay for tuberculous pericarditis: A systematic review and meta-analysis

Objective

The purpose of this study was to evaluate the diagnostic efficacy of Xpert MTB/RIF for tuberculous pericarditis (TBP).

Methods

We searched relevant databases for Xpert MTB/RIF for TBP diagnosis until April 2021 and screened eligible studies for study inclusion. We evaluated the effectiveness of Xpert MTB/RIF when the composite reference standard (CRS) and mycobacterial culture were the gold standards, respectively. We performed meta-analyses using a bivariate random-effects model, and when the heterogeneity was obvious, the source of heterogeneity was further discussed.

Results

We included seven independent studies comparing Xpert MTB/RIF with the CRS and six studies comparing it with culture. The pooled sensitivity, specificity, and area under the curve of Xpert MTB/RIF were 65% (95% confidence interval, 59–72%), 99% (97–100%), and 0.99 (0.97–0.99) as compared with the CRS, respectively, and 75% (53–88%), 99% (90–100%), and 0.94 (0.92–0.96) as compared with culture, respectively. There was no significant heterogeneity between studies when CRS was the gold standard, whereas heterogeneity was evident when culture was the gold standard.

Conclusions

The sensitivity of Xpert MTB/RIF for diagnosing TBP was moderate and the specificity was good; thus, Xpert MTB/RIF can be used in the initial diagnosis of TBP.

A rare case of constrictive pericarditis with Budd-Chiari syndrome due to right atrial thrombosis

Patients living with HIV (PLWH) with previous pulmonary tuberculosis, presenting with disproportionate ascites to peripheral congestion, should alert the clinician to consider constrictive pericarditis and Budd–Chiari syndrome (BCS). Constrictive pericarditis is the scarring and loss of the pericardial sac elasticity. The aetiology of constrictive pericarditis varies between developed and developing countries, with infective causes like tuberculosis being significant in South Africa. Budd–Chiari syndrome is a group of disorders characterised by hepatic venous outflow obstruction. The level of obstruction in Budd–Chiari syndrome varies globally. In Asia, South Africa, India, and China, obstruction is predominantly found in the inferior vena cava while in Western countries, hepatic vein obstruction occurs. Patients living with HIV are at increased risk of arterial and venous thromboembolism. The clinician must consider Budd–Chiari syndrome in patients living with HIV presenting with ascites. In patients living with HIV, tuberculosis co-infection has been associated with a higher risk of pericarditis. Both constrictive pericarditis and Budd–Chiari syndrome share a remarkably similar clinical presentation, with ascites and hepatomegaly. There is a dearth of literature on co-existent constrictive pericarditis and Budd–Chiari syndrome. We describe a 31-year-old HIV-infected female, on anti-retroviral therapy (CD4 count 208 cells/uL, undetected viral load), with previous pulmonary tuberculosis, who presented with a 2-month history of abdominal swelling, peripheral oedema, and New York Heart Association grade 4 dyspnoea. Examination revealed an elevated jugular venous pulsation with CV waves, atrial fibrillation, right-sided S3 gallop, pansystolic murmur (3/6) at the left sternal border, tender hepatomegaly, and massive ascites with minimal peripheral oedema. The discordant size of ascites prompted investigations, namely, ultrasound abdomen, echocardiogram, and computed tomography (chest and abdomen). These revealed constrictive pericarditis and Budd–Chiari syndrome with thrombus formation in the right atrium, hepatic vein, and inferior vena cava. She was initiated onto anti-coagulation, anti-tuberculosis therapy and referred for pericardiectomy. Clinicians must maintain a suspicion for constrictive pericarditis and Budd–Chiari syndrome in HIV-infected patients, especially in those with a previous tuberculosis, presenting with features of right heart failure.

Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance

Pathogenic Mycobacterium tuberculosis complex organisms (MTBC) primarily cause pulmonary tuberculosis (PTB); however, MTBC are also capable of causing disease in extrapulmonary (EP) organs, which pose a significant threat to human health worldwide. Extrapulmonary tuberculosis (EPTB) accounts for about 20–30% of all active TB cases and affects mainly children and adults with compromised immune systems. EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB, and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum, and the genitourinary system as primary and/or disseminated disease. EPTB diagnosis involves clinical, radiological, microbiological, histopathological, biochemical/immunological, and molecular methods. However, only culture and molecular techniques are considered confirmatory to differentiate MTBC from any non-tuberculous mycobacteria (NTM) species. While EPTB due to MTBC responds to first-line anti-TB drugs (ATD), drug susceptibility profiling is an essential criterion for addressing drug-resistant EPTB cases (DR-EPTB). Besides antibiotics, adjuvant therapy with corticosteroids has also been used to treat specific EPTB cases. Occasionally, surgical intervention is recommended, mainly when organ damage is debilitating to the patient. Recent epidemiological studies show a striking increase in DR-EPTB cases ranging from 10–15% across various reports. As a neglected disease, significant developments in rapid and accurate diagnosis and better therapeutic interventions are urgently needed to control the emerging EPTB situation globally. In this review, we discuss the recent advances in the clinical diagnosis, treatment, and drug resistance of EPTB.

Diagnostic accuracy of the Xpert MTB/RIF assay for tuberculous pericarditis: A protocol of systematic review and meta-analysis

BACKGROUND

Tuberculous pericarditis (TBP) can lead to serious consequences. Early diagnosis and treatment are very important for TBP, but early diagnosis is still very challenging. This study aims to evaluate the diagnostic accuracy of Xpert MTB/RIF for TBP using meta-analysis method.

METHODS

We will search Embase, PubMed, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and the Wanfang database for researches assessing the diagnostic accuracy of Xpert MTB/RIF for TBP until April 2021. Any types of study design with full text will be selected and included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool will be used to assess the risk of bias. We will use version 15.0 of the STATA software with the midas command packages to carry out meta-analyses.

RESULTS

Evidence for diagnostic accuracy of Xpert MTB/RIF for TBP will be provided through the study, and this protocol will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide evidence of Xpert MTB/RIF for TBP.

Unusual cause for loss of left ventricular capture in patient with cardiac resynchronization due to tuberculous pericarditis

We report a case of 37-year-old man implanted with cardiac resynchronization therapy-defibrillator presented with persistent low-grade fever and sudden loss of left ventricular (LV) capture from coronary sinus lead after generator replacement. ¹⁸ F-fluorodeoxyglucose positron emission tomography with computed tomography scan showed increased uptake at posterolateral region of the pericardium adjacent to the LV lead, suggestive of possible lead-related infection. Combined percutaneous and surgical lead extraction revealed purulent pericarditis and polymerase chain reaction testing confirmed tuberculous (TB) pericarditis. TB pericarditis is an unusual cause of loss of LV capture, but should be considered in countries where TB is still endemic.

Neglected cardiovascular diseases and their significance in the Global North

Due to increasing global migration, the spectrum of cardiovascular disease (CVD) is changing in developed countries. Up to 3% of migrants arriving in Europe have underlying CVD. Despite their high global prevalence, conditions such as rheumatic heart disease, Chagas disease, endomyocardial fibrosis, tuberculous pericarditis, peripartum cardiomyopathy, and pulmonary hypertension are often under-recognized, and, as a result, neglected in industrialized countries. Many of these conditions, and their causes, are often unfamiliar to the health-care providers in host countries. In this review, we summarize the epidemiology, etiology, clinical presentation, diagnostic work-up, and management of neglected CVDs that have an increasing prevalence in the Global North.

Diagnostic values of Xpert MTB/RIF, T-SPOT.TB and adenosine deaminase for HIV-negative tuberculous pericarditis in a high burden setting: a prospective observational study

The diagnosis of tuberculous pericarditis (TBP) remains challenging. This prospective study evaluated the diagnostic value of Xpert MTB/RIF (Xpert) and T-SPOT.TB and adenosine deaminase (ADA) for TBP in a high burden setting. A total of 123 HIV-negative patients with suspected TBP were enrolled at a tertiary referral hospital in China. Pericardial fluids were collected and subjected to the three rapid tests, and the results were compared with the final confirmed diagnosis. Of 105 patients in the final analysis, 39 (37.1%) were microbiologically, histopathologically or clinically diagnosed with TBP. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio (DOR) for Xpert were 66.7%, 98.5%, 96.3%, 83.3%, 44.0, 0.338, and 130.0, respectively, compared to 92.3%, 87.9%, 81.8%, 95.1%, 7.6, 0.088, and 87.0, respectively, for T-SPOT.TB, and 82.1%, 92.4%, 86.5%, 89.7%, 10.8, 0.194, and 55.8, respectively, for ADA (≥ 40 U/L). ROC curve analysis revealed a cut-off point of 48.5 spot-forming cells per million pericardial effusion mononuclear cells for T-SPOT.TB, which had a DOR value of 183.8, while a cut-off point of 41.5 U/L for ADA had a DOR value of 70.9. Xpert (Step 1: rule-in) followed by T-SPOT.TB [cut-off point] (Step 2: rule-out) showed the highest DOR value of 252.0, with only 5.7% (6/105) of patients misdiagnosed. The two-step algorithm consisting of Xpert and T-SPOT.TB could offer rapid and accurate diagnosis of TBP.

Tuberculous pericardial disease: a focused update on diagnosis, therapy and prevention of complications

Tuberculous pericarditis (TBP) is the most important manifestation of tuberculous heart disease and is still associated with a significant morbidity and mortality in TB endemic areas. The high prevalence of the disorder over the last 3 decades has been fueled by the human immunodeficiency virus/AIDS (HIV/AIDS) pandemic in these areas. The objective of this review is to provide a focused update on developments in the diagnosis and therapy of this condition, prevention of its complications, as well as future novel therapies. The definitive diagnosis of a tuberculous etiology in patients with suspected TBP continues to pose a challenge for clinicians. Clinical prediction scores, although never formally validated have been used with some success. However, they may be prone to both over and underdiagnosis due to lack of pericardial fluid analysis. Recent studies evaluating Xpert MTB/RIF, suggest that this advanced polymerase chain reaction (PCR) based technology does not provide increased accuracy compared to earlier iterations. However a combined two test approach starting with Xpert MTB/RIF followed by either adenosine deaminase (ADA) or interferon gamma (IFN-γ) may provide for significantly enhanced specificity and sensitivity cost permitting. Pericardiocentesis remains the gold standard for managing the compressive pericardial fluid and its adverse hemodynamic sequelae. A four drug anti-TB drug regimen at standard doses and duration is recommended. However recent evidence suggests that these drugs penetrate the pericardium very poorly potentially explaining the high mortality observed particularly in those who are culture positive with a high bacillary load. Constrictive pericarditis is the main long-term complication of TBP and is still a significant cause of heart failure in Sub-Saharan Africa. This is important because access to definitive surgical therapy where TBP is prevalent continues to be low, highlighting the need to develop strategies or interventions to prevent fibrosis and constriction. Recent detailed advanced studies of pericardial fluid in TBP have revealed a strong profibrotic transcriptomic profile, with high amounts of pro-inflammatory cytokines and low levels of the anti-fibrotic tetrapeptide N-Acetyl-Seryl-Aspartyl-Lysyl-Proline (Ac-SDKP). These new insights may explain in part the high propensity to fibrosis associated with the condition and offer hope for the future use of targeted therapy to interrupt pathways and mediators of tissue damage and subsequent maladaptive healing and fibrosis. The value of effective pericardiocentesis in reducing these pro-inflammatory and pro-fibrotic cytokines and peptides in an attempt to prevent pericardial constriction has yet to be established but has generated hypotheses for ongoing and future research.

The immunopathogenesis of tuberculous pericarditis

Tuberculous pericarditis is a severe form of extrapulmonary tuberculosis and is the commonest cause of pericardial effusion in high incidence settings. Mortality ranges between 8 and 34%, and it is the leading cause of pericardial constriction in Africa and Asia. Current understanding of the disease is based on models derived from studies performed in the 1940-50s. This review summarises recent advances in the histology, microbiology and immunology of tuberculous pericarditis, with special focus on the effect of Human Immunodeficiency Virus (HIV) and the determinants of constriction.

Diagnosis and Management of Tuberculous Pericarditis: What Is New?

PURPOSE OF REVIEW

This review provides an update on the immunopathogenesis of tuberculous pericarditis (TBP), investigations to confirm tuberculous etiology, the limitations of anti-tuberculous therapy (ATT), and recent efficacy trials.

RECENT FINDINGS

A profibrotic immune response characterizes TBP, with low levels of AcSDKP, high levels of γ-interferon and IL-10 in the pericardium, and high levels of TGF-β and IL-10 in the blood. These findings may have implications for future therapeutic targets. Despite advances in nucleic acid amplification approaches, these tests remain disappointing for TBP. Trials of corticosteroids and colchicine have had mixed results, with no impact on mortality, evidence of a reduction in rates of constrictive pericarditis and potential harm in those with advanced HIV. Small studies suggest that ATT penetrates the pericardium poorly. Given that there is a close association between high bacillary burden and mortality, a rethink about the optimal drug doses and duration may be required. The high mortality and morbidity from TBP despite use of anti-tuberculous drugs call for researches targeting host-directed immunological determinants of treatment outcome. There is also a need for the identification of steps in clinical management where interventions are needed to improve outcomes.

[Management of pericarditis and pericardial effusion, constrictive and effusive-constrictive pericarditis]

This CME review takes stock of the progress in the etiology, pathophysiology, diagnostics and treatment of pericarditis and pericardial effusion brought about by the publication of the 2nd European Society of Cardiology (ESC) guidelines on the management of pericardial diseases in 2015. It also emphasizes special forms, which have received less attention in the past, such as therapy-refractory (incessant), effusive-constrictive and constrictive pericarditis and the treatment of acute and recurrent pericarditis with colchicine. After the diagnosis of pericarditis with or without effusion has been made, the first step is to clarify its etiology, which affects the clinical symptoms, course, treatment and the prognosis. In this aspect the requirements of the guidelines and the reality of an etiological classification of pericardial diseases diverge in many cases. The diagnosis of "idiopathic" acute or recurrent pericarditis is still much too often the result of insufficient efforts to find the cause. Too often only malignant and bacterial forms are excluded. If the etiology is known local intrapericardial treatment with the already inserted pigtail catheter from the diagnostic pericardial puncture can be carried out with few systemic side effects. The 2015 ESC guidelines recommend colchicine as first line treatment in all forms of pericarditis except for neoplastic pericardial effusion. It accelerates healing and reduces the frequency of recurrence of pericarditis but cannot eliminate recurrence completely. The best treatment and prevention of recurrence is the eradication of the underlying etiological cause.

Tuberculous pericarditis mimicking multiple tumors in pericardial effusion

Tuberculosis is still the leading cause of pericardial disease in developing nations. A definite diagnosis of tuberculosis is usually relatively difficult, especially when its manifestations are not typical. We report a 19-year-old man who presented with chest obstruction, shortness of breath, edema of the lower extremities, and mild fever for 14 days. The manifestations of tuberculosis pneumonia were not typical, except for a small high-density shadow in the left upper lung field near the pleura, with a small amount of pleural effusion on chest computed tomography. The tuberculin skin test, acid-fast stain of sputum and pericardial effusion, and bacterial culture showed negative results. Echocardiography showed three free-floating irregular masses in a large amount of pericardial effusion. The masses and exudates were removed by pericardiectomy. The masses were composed of hyperplastic granulation tissue and dead tissue without a normal architecture, mixed with numerous caseous substances, which confirmed the diagnosis of tuberculous pericarditis. This is a unique report of a patient who presented with tuberculous pericarditis with multiple solid masses in a large amount of pericardial effusion, without typical clinical manifestations of tuberculosis.

Acute purulent pericarditis due co-infection with Staphylococcus aureus and Mycobacterium tuberculosis as first manifestation of HIV infection

Background

Purulent pericarditis is an unusual first manifestation of HIV-infected patients. Co-infections in this scenario are possible and challenging. Mycobacterium tuberculosis is a frequent agent in purulent pericarditis related to HIV infection but co-infection with Staphylococcus aureus is rarely reported.

Case presentation

We describe a rare case in otherwise asymptomatic 39-year-old diabetic man with acute purulent pericarditis leading to tamponade due to S. aureus and evidences of M. tuberculosis co-infection. Testing for human immunodeficiency virus was positive.

Conclusion

Primary purulent pericarditis is a rare condition and may indicate underlying HIV infection. In this scenario, coinfection with multiple organisms are possible and patient should be tested for underlying tuberculosis in addition to standard microbiological workup.

Inflammation and pericarditis: Are neutrophils actors behind the scenes?

The morbidity of acute pericarditis is increasing over time impacting on patient quality of life. Recent clinical trials focused especially on clinical aspects, with a modest interest in pathophysiological mechanisms. This narrative review, based on papers in English language obtained via PubMed up to April 2018, aims at focusing on the role of the innate immunity in pericarditis and discussing future potential therapeutic strategies impacting on disease pathophysiology. In developed countries, most cases of pericarditis are referred to as idiopathic, although etiological causes have been described, with autoreactive/lymphocytic, malignant, and infectious ones as the most frequent causes. Apart the known impairment of the adaptive immunity, recently a large body evidence indicated the central role of the innate immune system in the pathogenesis of recurrent pericarditis, starting from similarities with autoinflammatory diseases. Accordingly, the "inflammasome" has been shown to behave as an important player in pericarditis development. Similarly, the beneficial effect of colchicine in recurrent pericarditis confirms that neutrophils are important effectors as colchicine, which can block neutrophil chemotaxis, interferes with neutrophil adhesion and recruitment to injured tissues and abrogate superoxide production. Anyway, the role of the adaptive immune system in pericarditis cannot be reduced to a black or white issue as mechanisms often overlap. Therefore, we believe that more efficient therapeutic strategies have to be investigated by targeting neutrophil-derived mediators (such as metalloproteinases) and disentangling the strict interplay between neutrophils and platelets. In this view, some progress has been done by using the recombinant human interleukin-1 receptor antagonist anakinra.

Suspected Pericardial Tuberculosis Revealed as an Amyloid Pericardial Mass

Primary systemic amyloidosis is not easily diagnosed. The immunoglobulin deposits are usually localized in the kidney, heart, and liver. We describe an unusual case of a patient suffering from a pericardial amyloidoma with internal calcifications and air bubbles that compressed the right ventricle and shifted the heart to the left. Since the patient was in shock, urgent pericardiotomy was performed. This site showed PET uptake. A monoclonal component was present. On these findings, differential diagnoses included multiple myeloma and atypical pericardial tuberculosis, whereas a periumbilical fat tissue biopsy demonstrated amyloidosis. A previous Salmonella species infection had most likely stimulated the production of amyloid. The patient received bortezomib/dexamethasone treatment and achieved a good response.

Corticosteroids as an adjunct to tuberculosis therapy

INTRODUCTION

Inflammation, or the prolonged resolution of inflammation, contributes to death from tuberculosis. Interest in inflammatory mechanisms and the prospect of beneficial immune modulation as an adjunct to antibacterial therapy has revived and the concept of host directed therapies has been advanced. Such renewed attention has however, overlooked the experience of such therapy with corticosteroids. Areas covered: The authors conducted literature searches and evaluated randomized clinical trials, systematic reviews and current guidelines and summarize these findings. They found evidence of benefit in meningeal and pericardial tuberculosis in HIV-1 uninfected persons, but less so in those HIV-1 coinfected and evidence of harm in the form of opportunist malignancy in those not prescribed antiretroviral therapy. Adjunctive corticosteroids are however of benefit in the treatment and prevention of paradoxical HIV-tuberculosis immune reconstitution inflammatory syndrome. Expert commentary: Further high-quality clinical trials and experimental medicine studies are warranted and analysis of materials arising from such studies could illuminate ways to improve corticosteroid efficacy or identify novel pathways for more specific intervention.

Established and novel pathophysiological mechanisms of pericardial injury and constrictive pericarditis

This review article aims to: (1) discern from the literature the immune and inflammatory processes occurring in the pericardium following injury; and (2) to delve into the molecular mechanisms which may play a role in the progression to constrictive pericarditis. Pericarditis arises as a result of a wide spectrum of pathologies of both infectious and non-infectious aetiology, which lead to various degrees of fibrogenesis. Current understanding of the sequence of molecular events leading to pathological manifestations of constrictive pericarditis is poor. The identification of key mechanisms and pathways common to most fibrotic events in the pericardium can aid in the design and development of novel interventions for the prevention and management of constriction. We have identified through this review various cellular events and signalling cascades which are likely to contribute to the pathological fibrotic phenotype. An initial classical pattern of inflammation arises as a result of insult to the pericardium and can exacerbate into an exaggerated or prolonged inflammatory state. Whilst the implication of major drivers of inflammation and fibrosis such as tumour necrosis factor and transforming growth factor β were foreseeable, the identification of pericardial deregulation of other mediators (basic fibroblast growth factor, galectin-3 and the tetrapeptide Ac-SDKP) provides important avenues for further research.

Acquired heart disease in low-income and middle-income countries

The burden of illness associated with acquired cardiac disease in children in low-income and middle-income countries (LMIC) is significant and may be equivalent to that of congenital heart disease. Rheumatic heart disease, endomyocardial fibrosis, cardiomyopathy (including HIV cardiomyopathy) and tuberculosis are the most important causes. All are associated with poverty with the neediest children having the least access to care. The associated mortality and morbidity is high. There is an urgent need to improve cardiac care in LMIC, particularly in sub-Saharan Africa and parts of Southeast Asia where the burden is highest.

Comparison between the diagnostic validities of Xpert MTB/RIF and interferon-γ release assays for tuberculous pericarditis using pericardial tissue

BACKGROUND

This study aimed to assess the diagnostic performance of Xpert MTB/RIF for tuberculous pericarditis (TBP) using pericardial tissues.

METHODS

The study involved 30 patients admitted with suspected TBP from January-December 2016; three patients were later excluded. The interferon-γ release assay (T-SPOT.TB) and the Xpert MTB/RIF test were performed using peripheral blood and pericardial tissues, respectively. TBP was confirmed using pericardial histopathology and a composite reference standard (CRS). We analyzed the sensitivity, specificity, predictive value (PV), likelihood ratio (LR), and area under curve (AUC) of both assays.

RESULTS

Fourteen patients were confirmed as TBP, 10 as non-TBP, and 3 as probable TBP. The sensitivity, specificity, positive PV (PPV), negative PV (NPV), PLR, NLR, and AUC (95% confidence interval [CI]) of the Xpert MTB/RIF assay were 78.6% (49.2-95.3%) and 70.6% (44.0-89.7%); 92.3% (64.0-99.8%) and 100% (69.2-100%); 91.7% (61.5-99.8%) and 100% (73.5-100%); 80.0% (51.9-95.7%) and 66.7% (38.4-88.2%); 10.21 (1.52-68.49) and the PLR value was undefined with CRS as the reference; 0.23 (0.08-0.64) and 0.29(0.14-0.61); and 0.854 (0.666-0.959) and 0.853 (0.664-0.959), against histopathology and CRS, respectively. The sensitivity, specificity, PPV, NPV, PLR, NLR, and AUC values (95% CI) of T-SPOT.TB were 92.9% (66.1-99.8%) and 94.1% (71.3-99.9%); 15.4% (1.9-45.5%) and 20.0% (2.5-55.6%); 54.2% (32.8-74.5%) and 66.7% (44.7-84.4%); 66.7% (9.4-99.2%) and 66.7% (9.4-99.2%); 1.10 (0.83-1.44) and 1.18 (0.84-1.6); 0.46 (0.05-4.53) and 0.29 (0.03-2.85); and 0.541(0.340-0.733) and 0.571(0.367-0.758), against histopathology and CRS, respectively. The differences in sensitivity, PPV, and AUC of Xpert MTB/RIF and T-SPOT.TB were not statistically significant (P > 0.05), compared to those of histopathology and CRS. However, the differences in specificity and NPV of the two assays were significant (P < 0.05), compared to those of histopathology and CRS.

CONCLUSIONS

Xpert MTB/RIF test is a valid diagnostic technique for TBP with higher sensitivity and specificity than T-SPOT.TB.

Tuberculosis

Tuberculosis (TB) is currently the world's leading cause of infectious mortality. Imaging plays an important role in the management of this disease. The complex immune response of the human body to Mycobacterium tuberculosis results in a wide array of clinical manifestations, making clinical and radiological diagnosis challenging. ¹⁸F-FDG-PET/CT is very sensitive in the early detection of TB in most parts of the body; however, the lack of specificity is a major limitation. ¹⁸F-FDG-PET/CT images the whole body and provides a pre-therapeutic metabolic map of the infection, enabling clinicians to accurately assess the burden of disease. It enables the most appropriate site of biopsy to be selected, stages the infection, and detects disease in previously unknown sites. ¹⁸F-FDG-PET/CT has recently been shown to be able to identify a subset of patients with latent TB infection who have subclinical disease. Lung inflammation as detected by ¹⁸F-FDG-PET/CT has shown promising signs that it may be a useful predictor of progression from latent to active infection. A number of studies have identified imaging features that might improve the specificity of ¹⁸F-FDG-PET/CT at some sites of extrapulmonary TB. Other PET tracers have also been investigated for their use in TB, with some promising results. The potential role and future perspectives of PET/CT in imaging TB is considered. Literature abounds on the very important role of ¹⁸F-FDG-PET/CT in assessing therapy response in TB. The use of ¹⁸F-FDG for monitoring response to treatment is addressed in a separate review.

Interventions for treating tuberculous pericarditis

BACKGROUND

Tuberculous pericarditis can impair the heart's function and cause death; long term, it can cause the membrane to fibrose and constrict causing heart failure. In addition to antituberculous chemotherapy, treatments include corticosteroids, drainage, and surgery.

OBJECTIVES

To assess the effects of treatments for tuberculous pericarditis.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register (27 March 2017); the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library (2017, Issue 2); MEDLINE (1966 to 27 March 2017); Embase (1974 to 27 March 2017); and LILACS (1982 to 27 March 2017). In addition we searched the metaRegister of Controlled Trials (mRCT) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal using 'tuberculosis' and 'pericard*' as search terms on 27 March 2017. We searched ClinicalTrials.gov and contacted researchers in the field of tuberculous pericarditis. This is a new version of the original 2002 review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search outputs, evaluated study eligibility, assessed risk of bias, and extracted data; and we resolved any discrepancies by discussion and consensus. One trial assessed the effects of both corticosteroid and Mycobacterium indicus pranii treatment in a two-by-two factorial design; we excluded data from the group that received both interventions. We conducted fixed-effect meta-analysis and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Seven trials met the inclusion criteria; all were from sub-Saharan Africa and included 1959 participants, with 1051/1959 (54%) HIV-positive. All trials evaluated corticosteroids and one each evaluated colchicine, M. indicus pranii immunotherapy, and open surgical drainage. Four trials (1841 participants) were at low risk of bias, and three trials (118 participants) were at high risk of bias.In people who are not infected with HIV, corticosteroids may reduce deaths from all causes (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.59 to 1.09; 660 participants, 4 trials, low certainty evidence) and the need for repeat pericardiocentesis (RR 0.85, 95% CI 0.70 to 1.04; 492 participants, 2 trials, low certainty evidence). Corticosteroids probably reduce deaths from pericarditis (RR 0.39, 95% CI 0.19 to 0.80; 660 participants, 4 trials, moderate certainty evidence). However, we do not know whether or not corticosteroids have an effect on constriction or cancer among HIV-negative people (very low certainty evidence).In people living with HIV, only 19.9% (203/1959) were on antiretroviral drugs. Corticosteroids may reduce constriction (RR 0.55, 0.26 to 1.16; 575 participants, 3 trials, low certainty evidence). It is uncertain whether corticosteroids have an effect on all-cause death or cancer (very low certainty evidence); and may have little or no effect on repeat pericardiocentesis (RR 1.02, 0.89 to 1.18; 517 participants, 2 trials, low certainty evidence).For colchicine among people living with HIV, we found one small trial (33 participants) which had insufficient data to make any conclusions about any effects on death or constrictive pericarditis.Irrespective of HIV status, due to very low certainty evidence from one trial, it is uncertain whether adding M. indicus pranii immunotherapy to antituberculous drugs has an effect on any outcome.Open surgical drainage for effusion may reduce repeat pericardiocentesis In HIV-negative people (RR 0.23, 95% CI 0.07 to 0.76; 122 participants, 1 trial, low certainty evidence) but may make little or no difference to other outcomes. We did not find an eligible trial that assessed the effects of open surgical drainage in people living with HIV.The review authors found no eligible trials that examined the length of antituberculous treatment needed nor the effects of other adjunctive treatments for tuberculous pericarditis.

AUTHORS' CONCLUSIONS

For HIV-negative patients, corticosteroids may reduce death. For HIV-positive patients not on antiretroviral drugs, corticosteroids may reduce constriction. For HIV-positive patients with good antiretroviral drug viral suppression, clinicians may consider the results from HIV-negative patients more relevant.Further research may help evaluate percutaneous drainage of the pericardium under local anaesthesia, the timing of pericardiectomy in tuberculous constrictive pericarditis, and new antibiotic regimens.

Cardiac Disease Associated with Human Immunodeficiency Virus Infection

Over the last 2 decades human immunodeficiency virus (HIV) infection has become a chronic disease requiring long-term management. Aging, antiretroviral therapy, chronic inflammation, and several other factors contribute to the increased risk of cardiovascular disease in patients infected with HIV. In low-income and middle-income countries where antiretroviral therapy access is limited, cardiac disease is most commonly related to opportunistic infections and end-stage manifestations of HIV/acquired immunodeficiency syndrome, including HIV-associated cardiomyopathy, pericarditis, and pulmonary arterial hypertension. Cardiovascular screening, prevention, and risk factor management are important factors in the management of patients infected with HIV worldwide.

Tuberculosis and the Heart

Owing to the high prevalence of tuberculosis (TB) and human immunodeficiency virus/AIDS, tuberculous heart disease remains an important problem in TB endemic areas. In this review, we reiterate salient aspects of the traditional understanding and approach to its management, and provide important updates on the pathophysiology, diagnosis, and treatment garnered over the past decade of focused clinical and basic science research. We emphasize that, if implemented widely, these improved evidence-based approaches to the disease can build on the early progress made in treating tuberculous heart disease and help further the goal of significantly reducing its historically high morbidity and mortality.

The heart of Africa: succeeding against the odds

South Africa and other areas of sub-Saharan Africa have in the past 20 years undergone rapid demographical changes, largely due to urbanisation and changes in lifestyle. This rapid change has led to a marked increase in specific cardiac conditions, such as hypertensive heart disease and coronary artery disease (with the highest prevalence in the middle-aged population), in conjunction with a range of other heart diseases, which are historically common in Africa-eg, rheumatic heart disease, cardiomyopathies, and unoperated congenital heart disease. The short supply of well-equipped screening facilities, late diagnosis, and inadequate care at primary, secondary, and tertiary levels have led to a large burden of patients with poorly treated heart failure. Excellent progress has been made in the understanding of the epidemiology, sociodemographical factors, effect of urbanisation, and pathophysiology of cardiac conditions, such as peripartum cardiomyopathy, rheumatic heart disease, and tuberculous pericarditis, which are common in sub-Saharan Africa. This progress has been achieved largely through several studies, such as the Heart of Soweto, THESUS, REMEDY, BA-HEF, Abeokuta-HF, and the PAPUCO studies. Studies on the suitable therapeutic management of several heart conditions have also been done or are underway. In this Lecture, I provide a personal perspective on the evolving burden of cardiac disease, as witnessed since my appointment at Chris Hani Baragwanath Hospital, in Soweto, South Africa, in 1992, which was also the year that the referendum to end apartheid in South Africa was held. Subsequently, a network of cardiologists was formed under the umbrella of the Heart of Africa Studies and the Pan African Cardiac Society. Furthermore, I summarise the major gaps in the health-care system dealing with the colliding epidemic of communicable and non-communicable heart diseases, including cardiac diseases common in peripartum women. I also touch on the fantastic opportunities available for doing meaningful research with enthusiastic colleagues and, thereby, having a large effect, despite the need to be highly innovative in finding much needed funding support.

F-18 FDG PET/CT imaging of cardiac and vascular inflammation and infection

INTRODUCTION

Inflammation forms an important core of the aetiopathogenic process involved in many diseases affecting the heart and the blood vessels. These diseases include infections as well as inflammatory non-infectious cardiovascular conditions. The common feature of this is invasion of the heart or blood vessel by inflammatory cells. F-18 2-fluoro 2-deoxy-D glucose (FDG) is an analogue of glucose and like glucose it is taken up by activated inflammatory cells that accumulate at the site of infection. This has formed the basis of the use of F-18 FDG PET/CT in the non-invasive evaluation of human inflammatory diseases.

SOURCES OF DATA

This review is based on the published academic articles as well as our clinical experience.

AREAS OF AGREEMENT

F-18 FDG PET/CT is a useful imaging modality in the evaluation of cardiovascular inflammatory disorders. Accumulation and distribution of F-18 FDG at the site of inflammation/infection corresponds to severity of the inflammation/infection and extent of involvement.

AREAS OF CONTROVERSY

Most studies evaluating utility of F-18 FDG PET/CT in imaging cardiovascular inflammation are small observational studies hence are potentially prone to bias.

GROWING POINTS

Being a hybrid metabolic and morphologic imaging technique, F-18 FDG PET/CT offers combined advantage of complementary anatomic and metabolic information in disease process. This makes it a useful modality in the diagnosis, determination of extent of disease, prognostication as well as treatment monitoring.

AREAS TIMELY FOR DEVELOPING RESEARCH

Larger prospective studies are needed to validate the superiority of F-18 FDG PET/CT imaging over conventional anatomic imaging modalities.

Predictive factors for unfavorable outcomes of tuberculous pericarditis in human immunodeficiency virus-uninfected patients in an intermediate tuberculosis burden country

BACKGROUND

In areas where Mycobacterium tuberculosis is endemic, tuberculosis is known to be the most common cause of pericarditis. However, the difficulty in diagnosis may lead to late complications such as constrictive pericarditis and increased mortality. Therefore, identification of patients at a high risk for poor prognosis, and prompt initiation of treatment are important in the outcome of TB pericarditis. The aim of this study is to identify the predictive factors for unfavorable outcomes of TB pericarditis in HIV-uninfected persons in an intermediate tuberculosis burden country.

METHODS

A retrospective review of 87 cases of TB pericarditis diagnosed at a tertiary referral hospital in South Korea was performed. Clinical characteristics, treatment outcomes, complications during treatment, duration of treatment, and medication history were reviewed. Unfavorable outcome was defined as constrictive pericarditis identified on echocardiography performed 3 to 6 months after initial diagnosis of TB pericarditis, cardiac tamponade requiring emergency pericardiocentesis, or death. Predictive factors for unfavorable outcomes were identified.

RESULTS

Of the 87 patients, 44 (50.6%) had unfavorable outcomes; cardiac tamponade (n = 36), constrictive pericarditis (n = 18), and mortality (n = 4). 14 patients experienced both cardiac tamponade and constrictive pericarditis. During a 1 year out-patient clinic follow up, 4 patients required repeat pericardiocentesis and pericardiectomy was performed in 0 patients. In the multivariate analysis, patients with large amounts of pericardial effusion (P = .003), those with hypoalbuminemia (P = .011), and those without cardiovascular disease (P = .011) were found to have a higher risk of unfavorable outcomes.

CONCLUSION

HIV-uninfected patients with TB pericarditis are at a higher risk for unfavorable outcomes when presenting with low serum albumin, with large pericardial effusions, and without cardiovascular disease.

[Progress or regress or both? ESC guidelines on pericardial diseases 2015]

Eleven years after the publication of the first guidelines worldwide on pericardial diseases by the European Society of Cardiology (ESC), the international expert group of the ESC has updated the original document of 28 pages with 275 references. The final version of the new guidelines is more voluminous with 44 pages of recommendations but only 233 references. A continuing medical education (CME) certified update of the 2004 guidelines was published in the journal Herz volume 7/2014. In comparison to 2004 the 2015 guidelines have remained virtually unchanged in the sections detailing diagnostics, differential diagnosis, pathology and pathophysiology. Substantial progress has been made in magnetic resonance imaging (MRI) of pericarditis and epicarditis and in the practically universal recommendation of colchicine for all forms of pericarditis and pericardial effusion, whether acute, chronic or recurrent. This can truly be called progress; however, little has changed since 2004 even in tertiary referral centers or universities with respect to the etiological classification of acute or recurrent forms of pericarditis or pericardial effusion. By classifying pericardial syndromes much too often as idiopathic when a malignant or bacterial cause has been excluded, the underlying cause is often overlooked. Standstill in diagnosis is in the end regress because we too often lag behind our actual diagnostic and interventional possibilities.

Infection

Community-Acquired Pneumonia (CAP) is the first leading cause of death due to infection worldwide.Many gram-positive, gram-negative bacteria, funguses and viruses can cause the infectious pulmonary disease, and the severity of pneumonia depends on the balance between the microorganism charge, the body immunity defenses and the quality of the underlying pulmonary tissue. The microorganisms may reach the lower respiratory tract from inhaled air or from infected oropharyngeal secretions. The same organism may produce several different patterns that depend on the balance between the microorganism charge and the body immunity defenses.CAP is classified into three main groups: lobar pneumonia, bronchopneumonia and interstitial pneumonia.Lobar pneumonia is characterized by the filling of alveolar spaces by edema full of white and inflammatory cells. Necrotizing pneumonia consists of a fulminant process associated with focal areas of necrosis that results in abscesses. Bronchopneumonia or lobular pneumonia, is characterized by a peribronchiolar inflammation with thickening of peripheral bronchial wall, the diffusion of inflammation to the centrilobular alveolar spaces and development of nodules.The interstitial pneumonia represents with the destruction and esfoliation of the respiratory ciliated and mucous cells. The interstitial septa, the bronchial and bronchiolar walls become thickened for the inflammation process and lymphocytes interstitial infiltrates.Chest radiography represents an important initial examination in all patients suspected of having pulmonary infection and for monitoring response to therapy.Its role is to identify the pulmonary opacities, their internal characteristics and distribution, pleural effusion and presence of other complications as abscesses and pneumothorax.High spatial CT resolution allows accurate assessment of air space inflammation.The CT findings include nodules, interlobular septal thickening, intralobular reticular opacities, ground-glass opacities, tree-in-bud pattern, lobar-segmental consolidation, lobular consolidation, abscesses, pneumatocele, pleural effusion, pericardial effusion, mediastinal and hilar lymphoadenopaties, airway dilatation and emphysema.