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Singh A, Bernal EC, Dunn S, Vemulapalli R. Unveiling the Intrusion: An Emergent Journey Into Tuberculous Pericarditis. Cureus 2024; 16:e65093. [PMID: 39171045 PMCID: PMC11337732 DOI: 10.7759/cureus.65093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
We present an interesting case of mycobacterial tuberculosis pericarditis presenting as effusive constrictive pericarditis with early cardiac tamponade in a young Mexican migrant of Haitian descent. The patient underwent a pericardial window and was treated with rifampin, isoniazid, pyrazinamide, ethambutol, and vitamin B6. After further receiving steroids, the patient was doing well and was discharged home safely.
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Affiliation(s)
- Ashmin Singh
- Internal Medicine, Bayhealth Hospital, Dover, USA
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Abdelghani MS, Chapra A, Al‐Qudah B, Bishawi A, Shebani A, Obeidat I, Habib MB. Extrapulmonary tuberculosis presenting as hemorrhagic pleuro-pericardial effusions with pericardial mass. Clin Case Rep 2024; 12:e8619. [PMID: 38562572 PMCID: PMC10982116 DOI: 10.1002/ccr3.8619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/01/2024] [Accepted: 02/12/2024] [Indexed: 04/04/2024] Open
Abstract
Key Clinical Message Tuberculosis (TB) pericarditis, while uncommon, should be considered in patients with pericardial masses and effusion. Timely recognition and treatment with anti-TB medications are crucial for a successful outcome. Abstract TB pericarditis presenting as a pericardial mass is an unusual and rare manifestation of this disease. We report a 59-year-old South Asian male who presented with a 1-week history of dyspnea and cough. He was found to have a hemorrhagic pericardial mass with a massive pericardial effusion. Pleural fluid analysis was positive for TB. The patient was successfully treated with anti-TB medications. Although rare, tuberculous pericardial involvement should be suspected in patients presenting with symptoms of pericardial masses and effusion.
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Affiliation(s)
| | - Ammar Chapra
- Department of CardiologyHeart Hospital, Hamad Medical CorporationDohaQatar
| | - Bara Al‐Qudah
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Ahmed Bishawi
- Infectious Disease Division, Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Ahmed Shebani
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Ibrahim Obeidat
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Mhd Baraa Habib
- Department of CardiologyHeart Hospital, Hamad Medical CorporationDohaQatar
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Yucel E, Patel NK, Crousillat DR, Baliyan V, Jassar AS, Palacios I, Inglessis I, Smith RN. Case 32-2023: A 62-Year-Old Woman with Recurrent Hemorrhagic Pericardial Effusion. N Engl J Med 2023; 389:1511-1520. [PMID: 37851878 DOI: 10.1056/nejmcpc2115845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Affiliation(s)
- Evin Yucel
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - Nilay K Patel
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - Daniela R Crousillat
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - Vinit Baliyan
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - Arminder S Jassar
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - Igor Palacios
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - Ignacio Inglessis
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
| | - R Neal Smith
- From the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Massachusetts General Hospital, and the Departments of Medicine (E.Y., N.K.P., D.R.C., I.P., I.I.), Radiology (V.B.), Surgery (A.S.J.), and Pathology (R.N.S.), Harvard Medical School - both in Boston
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Bajpai J, Roy S, Shukla S, Pradhan A, Kant S, Shah S. Detection of drug-resistant Mycobacterium tuberculosis in pericardial fluid culture and its correlation with cartridge based nucleic acid amplification test and adenosine deaminase activity. Indian J Tuberc 2023; 71 Suppl 1:S59-S66. [PMID: 39067957 DOI: 10.1016/j.ijtb.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/22/2023] [Indexed: 07/30/2024]
Abstract
BACKGROUND Pericardial effusion is the accumulation of fluid in the pericardial cavity. In nations with high tuberculosis (TB) load, TB is the most common cause of pericardial effusion. 1-2% of patients with pulmonary TB develop Pericardial TB worldwide. Multi-drug-resistant (MDR) TB, including extrapulmonary TB (EPTB) cases, are rising in number. Adenosine Deaminase (ADA) is an enzyme in lymphocytes and myeloid cells, which has certain immune functions in the body. ADA levels are increased in inflammatory conditions, like pleural, pericardial, or joint effusions, of bacterial etiology, granulomatous conditions, neoplasms, and autoimmune pathologies. TB is the only lymphocytosis involving disease with increased ADA levels. MDR EPTB is rare, but cases are on the rise, and tuberculous pericardial effusion is one such example. Hence, it is important to know the percentage of cases detected by a culture that can be identified by cartridge-based nucleic acid amplification test (CBNAAT), their resistance patterns, and to identify potential markers like ADA, which can help in early identification of cases. The objectives of this study were to identify the Mycobacterium tuberculosis (MTB) bacilli in culture, and correlate them with cartridge-based nucleic acid amplification test (CBNAAT) results and their drug-resistance, in the Pericardial tubercular effusion, and to find if Adenosine Deaminase (ADA) levels can be used as a predictor of the presence of MTB in pericardial fluid. METHODOLOGY We enrolled 52 patients with moderate to large tuberculous pericardial effusion, based on pericardial fluid analysis, CBNAAT, and culture methods, between January 2021 and December 2021. RESULTS The mean age of the patients was 41.85 + 17.88 years, with a median of 38 years. Males made up 57.7% of the total patients. MTB was detected in 16 (30.8%) patients in the CBNAAT evaluations. 14 (87.5%) of the CBNAAT-positive TB patients were sensitive to Rifampicin, whereas the remaining 2 (12.5%) were resistant to Rifampicin on CBNAAT. MTB was found to be growing in 8 (15.38%) drug sensitivity test cultures. Out of these 8, 6 were sensitive to first-line drugs, whereas 2 were resistant to both Isoniazid and Rifampicin. The presence of cough was found to have a significant difference between CBNAAT-detected MTB positive and negative patients (p = 0.020), whereas an insignificant difference was found for the presence of hypertension, diabetes mellitus, obesity, dyspnea, or fever. There was also an insignificant difference between the number of patients positive for the Tuberculin skin test, between the two groups. ADA was significantly higher in the MTB-detected CBNAAT group (85.91 + 37.60U/L vs 39.78 + 24.31U/L, p = 0.005), whereas the total leukocyte count, lymphocytes, neutrophils, random blood sugar levels, and serum protein levels had no significant difference. The area under the Receiver Operator Curve (CBNAAT positive: dependent variable; ADA: test result variable) was 0.854 (null hypothesis rejected), with a standard error of 0.078. CONCLUSIONS Culture is the gold standard method to diagnose tuberculosis. Detection of MTB on pericardial fluid culture is very uncommon, though in our study, culture came out positive in 16% of patients, and 4% were resistant to rifampicin and isoniazid. Higher ADA levels in pericardial fluid are an indicator of tuberculous pericardial effusion.
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Affiliation(s)
- Jyoti Bajpai
- Department of Respiratory Medicine, Kasturba Chest Hospital, King George's Medical University, Lucknow, India
| | - Shubhajeet Roy
- Faculty of Medical Sciences, King George's Medical University, Lucknow, India
| | - Suruchi Shukla
- Department of Microbiology, King George's Medical University, Lucknow, India
| | - Akshyaya Pradhan
- Department of Cardiology, Lari Cardiology Centre, King George's Medical University, Lucknow, India.
| | - Surya Kant
- Department of Respiratory Medicine, Kasturba Chest Hospital, King George's Medical University, Lucknow, India
| | - Shobhit Shah
- Department of Cardiology, Lari Cardiology Centre, King George's Medical University, Lucknow, India
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Tran J, Green ON, Modahl L. Chest Manifestations of Mycobacterium Tuberculosis Complex - Clinical and Imaging Features. Semin Roentgenol 2022; 57:67-74. [DOI: 10.1053/j.ro.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
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Abstract
ABSTRACT Mycobacterium infection remains a leading cause of morbidity and mortality worldwide. Although rare, thoracic cardiovascular complications are associated with devastating consequences if not promptly diagnosed using computed tomography. Intrapulmonary complications include tuberculous aortitis, Rasmussen aneurysms, involvement of bronchial and nonbronchial systemic arteries, and thromboembolic events. Extrapulmonary complications include pericarditis, myocarditis, endocarditis, involvement of coronary arteries, annular-subvalvular left ventricle aneurysms and mediastinal fibrosis. This article will review these complications and their computed tomography features.
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Swaminathan A, du Cros P, Achar J, Kliescikova J, Mirgayosieva S, Pirmahmadzoda B. A case report of a child with probable drug resistant tuberculous pericarditis with a review of challenges involved in diagnosis, treatment and follow up of children with DR-TB pericarditis. BMC Infect Dis 2020; 20:298. [PMID: 32321429 PMCID: PMC7178721 DOI: 10.1186/s12879-020-05027-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 04/12/2020] [Indexed: 01/23/2023] Open
Abstract
Background There are unique challenges in the diagnosis and management of multi drug resistant tuberculosis (MDR-TB) in children. It is difficult to obtain confirmatory microbiological diagnosis in TB pericarditis. It is essential to differentiate between drug sensitive and drug resistant forms of TB as it has a major bearing on the regimen used, and inappropriate TB treatment combined with steroid use for pericarditis can lead to deterioration. With lack of samples, the treatment decision relies on the drug resistance pattern of the close contact if available. Therapeutic challenges of MDR-TB management in a child involve use of toxic drugs that need to be judiciously handled. We report a 2 years 4 months old male child who was diagnosed with TB pericarditis and treated based on the resistance pattern of his mother who was on treatment for pulmonary MDR-TB. Case presentation This 2 years 4 months old male child was diagnosed with TB involving his pericardium. Getting him started on an appropriate regimen was delayed due to the difficulty in establishing microbiological confirmation and drug susceptibility. He was commenced on a regimen based on his mother’s drug resistance pattern and required surgery due to cardiac failure during the course of his treatment. He successfully completed 2 years of therapy. Conclusions This child’s case demonstrates that despite unique challenges in diagnosis and management of drug resistant extra pulmonary tuberculosis in children, treatment of even complex forms can be successful. The need for high suspicion of MDR-TB, especially when there is close contact with pulmonary TB, careful design of an effective regimen that is tolerated by the child, indications for invasive surgical management of pericarditis, appropriate follow-up and management of adverse effects are emphasised.
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Affiliation(s)
- Aravind Swaminathan
- Médecins Sans Frontières (MSF), Dushanbe, Tajikistan. .,Clinical Fellow, Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK.
| | | | - Jay Achar
- Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | | | | | - Bobojon Pirmahmadzoda
- National Tuberculosis Programme, Ministry of Health and Social Protection of the Republic of Tajikistan, Dushanbe, Tajikistan
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Mathiasen VD, Frederiksen CA, Wejse C, Poulsen SH. A clinical case of tuberculosis with transient constrictive pericarditis and perimyocarditis. Echo Res Pract 2019; 6:K7-K12. [PMID: 31413861 PMCID: PMC6689120 DOI: 10.1530/erp-19-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 12/30/2022] Open
Abstract
Tuberculous pericarditis is a rare diagnosis seen among as few as 1% of tuberculosis (TB) patients in developed countries. We present a case of a 60-year-old male suffering from a transient constrictive pericarditis and subclinical involvement of the myocardium in a clinical case of tuberculous pericarditis with corresponding improvement after the initiation of anti-tuberculous treatment. We suggest monitoring of myocardial function using global longitudinal strain by myocardial speckle tracking strain analysis as supplement to routine left ventricular ejection fraction to assess clinical improvement in patients at risk of developing constrictive pericarditis. LEARNING POINTS Tuberculous pericarditis is rare and a diagnostic challenge in low-incidence countries.Patients with tuberculosis and involvement of the heart are at high risk of developing constrictive pericarditis.Novel imaging techniques, such as estimation of global longitudinal strain using myocardial speckle tracking analysis, may be useful in assessing cardiac involvement in tuberculosis patients.
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Affiliation(s)
- V D Mathiasen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Kobenhavn, Denmark
| | - C A Frederiksen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - C Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- Center for Global Health, Aarhus University, Aarhus, Denmark
| | - S H Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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10
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Abstract
Pericardial effusion is a common disease and tuberculosis (TB) accounts up to 4% of acute pericarditis with up to 7% of tamponade case. Accurate diagnosis is important while quick intervention can be life-saving. A case was reported involving a 73-year-old man who presented with reduced effort tolerance for one-month duration. During hospitalization, further workup revealed the presence of massive purulent pericardial effusion with evidence of tamponade. TB gene expert was positive in aspirated pericardial fluid and the patient was treated promptly using a combination of anti-TB drugs with the addition of steroid therapy.
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Affiliation(s)
| | | | - Firdaus Mat Lawi
- Internal Medicine, Hospital Sultanah Nur Zahirah, Terengganu, MYS
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Uchi T, Hakuno D, Fukae T, Takahashi M, Takiguchi S, Li HC, Nishizawa K, Nozaki H, Sueyoshi K. Armored Heart Because of Tuberculous Constrictive Pericarditis. Circ Cardiovasc Imaging 2019; 12:e008726. [PMID: 30803258 DOI: 10.1161/circimaging.118.008726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Takafumi Uchi
- Department of Internal Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (T.U., H.N.)
| | - Daihiko Hakuno
- Department of Cardiovascular Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (D.H., M.T., S.T., H.-C.L., K.N., K.S.)
| | - Tomoaki Fukae
- Department of Internal Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (T.F.)
| | - Masashi Takahashi
- Department of Cardiovascular Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (D.H., M.T., S.T., H.-C.L., K.N., K.S.)
| | - Shunichi Takiguchi
- Department of Cardiovascular Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (D.H., M.T., S.T., H.-C.L., K.N., K.S.)
| | - Hui-Chong Li
- Department of Cardiovascular Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (D.H., M.T., S.T., H.-C.L., K.N., K.S.)
| | - Kenya Nishizawa
- Department of Cardiovascular Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (D.H., M.T., S.T., H.-C.L., K.N., K.S.)
| | - Hiroyuki Nozaki
- Department of Internal Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (T.U., H.N.)
| | - Koichiro Sueyoshi
- Department of Cardiovascular Medicine, Kawasaki Municipal Hospital, Kanagawa, Japan (D.H., M.T., S.T., H.-C.L., K.N., K.S.)
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Abstract
Pericardial disease commonly occurs in the intensive care setting, but its timely diagnosis may be missed. The normal pericardium serves as a lubricated sac within which the heart may beat with minimal friction. The effect of the pericardium on cardiac filling at normal diastolic pressures is not clear; however, it may limit cardiac dilation in states of acute volume overload such as mitral regurgitation and right ventricular infarction. Pericardial disease may be divided into two catego ries : those cases that result from inflammation of the pericardium (pericarditis), and those cases in which a pericardial effusion or the thickened pericardium itself causes hemodynamic changes (tamponade and constric tion). Simple pericarditis should not lead to any hemo dynamic alteration other than tachycardia. In both tam ponade and constriction, the jugular venous pressure is elevated with low forward cardiac output; tamponade typically shows pulsus paradoxus, whereas constric tion more frequently shows Kussmaul's sign. The electrocardiogram may show diffuse ST segment elevation with PR segment depression in pericarditis; a large pericardial effusion, even with early tamponade, may not by itself cause any changes in the electrocar diogram. The echocardiogram is invaluable in diagnos ing the presence of a pericardial effusion and recogniz ing tamponade physiology (diastolic collapse of the right ventricular outflow tract and invagination of the right atrium). In selected patients, simple pericarditis may be managed outside of the hospital. Anyone suspected of having a hemodynamically significant pericardial effu sion should be hospitalized, usually in an intensive care unit. Pericardiocentesis should be performed under op timal monitoring conditions, although in an emergency, blind pericardiocentesis may be attempted. Recognition of the cause of the pericardial process will guide its treatment. Management of selected pericardial syn dromes is discussed later in this review.
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Affiliation(s)
- James D. Thomas
- Cardiology Unit, Medical Center Hospital of Vermont, Burlington, VT 05401
| | - Martin M. LeWinter
- Cardiology Unit, Medical Center Hospital of Vermont, Burlington, VT 05401
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Regional left atrial function differentiation in patients with constrictive pericarditis and restrictive cardiomyopathy: a study using speckle tracking echocardiography. Int J Cardiovasc Imaging 2015; 31:1529-36. [DOI: 10.1007/s10554-015-0726-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/25/2015] [Indexed: 12/27/2022]
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Decreased Metabolic Uptake in Tuberculous Pericarditis Indicating Response to Antituberculosis Therapy on FDG PET/CT. Clin Nucl Med 2014; 39:917-9. [DOI: 10.1097/rlu.0000000000000443] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Moolani Y, Bukhman G, Hotez PJ. Neglected tropical diseases as hidden causes of cardiovascular disease. PLoS Negl Trop Dis 2012; 6:e1499. [PMID: 22745835 PMCID: PMC3383757 DOI: 10.1371/journal.pntd.0001499] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Yasmin Moolani
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States of America
| | - Gene Bukhman
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Peter J. Hotez
- Sabin Vaccine Institute and Texas Children's Center for Vaccine Development, Department of Pediatrics (Section of Pediatric Tropical Medicine) and Molecular Virology & Microbiology, National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America
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Imazio M, Brucato A, Mayosi BM, Derosa FG, Lestuzzi C, Macor A, Trinchero R, Spodick DH, Adler Y. Medical therapy of pericardial diseases: part I: idiopathic and infectious pericarditis. J Cardiovasc Med (Hagerstown) 2010; 11:712-22. [PMID: 20736783 DOI: 10.2459/jcm.0b013e3283340b97] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The treatment of pericardial diseases is largely empirical because of the relative lack of randomized trials compared with other cardiovascular diseases. The main forms of pericardial diseases that can be encountered in the clinical setting include acute and recurrent pericarditis, pericardial effusion with or without cardiac tamponade, and constrictive pericarditis. Medical treatment should be targeted at the cause of the disease as much as possible. However, the cause of pericardial diseases may be varied and depends on the prevalence of specific diseases (especially tuberculosis). The search for an etiology is often inconclusive, and most cases are classified as idiopathic in developed countries where tuberculosis is relatively rare, whereas a tuberculous etiology is often presumed in developing countries where tuberculosis is endemic. The aim of the present article is to review current medical therapy for pericardial diseases, highlighting recent significant advances in clinical research, ongoing challenges and unmet needs. Following a probabilistic approach, the most common causes are considered (idiopathic, viral, tuberculous, purulent, connective tissue diseases and neoplastic pericardial disease). In this article, the therapy of idiopathic and more common forms of infectious pericarditis (viral and bacterial) is reviewed.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy.
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Myocarditis and pericarditis. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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18
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Abstract
Constrictive pericarditis (CP) is characterized by scarring and loss of elasticity of the pericardium, resulting in external impedance of cardiac filling. In the developed world, CP is most frequently encountered as a consequence of previous cardiac surgery, thoracic irradiation, viral or idiopathic causes. Tuberculosis still remains a common cause of CP in the developing world, immigrants from underdeveloped nations, and immunosuppressed patients. Clinical signs and symptoms of right heart failure coupled with risk factors for pericardial disease should raise suspicion for CP. Echocardiographic evaluation and often cardiac catheterization are essential components of accurate diagnosis of CP. Enhanced interventricular dependence, with respiratory variation in the ventricular pressures, and ventricular discordance are the pathophysiologic hallmarks of CP. Imaging findings such as increased pericardial thickness or pericardial calcification on computed tomography can be supportive, but are not necessary for the diagnosis of CP. Pericardiectomy remains the most effective therapy for symptomatic CP.
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Affiliation(s)
- Partho P Sengupta
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, USA
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19
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Abstract
The human immunodeficiency virus (HIV) epidemic has been associated with an increase in all forms of extrapulmonary tuberculosis including tuberculous pericarditis. Tuberculosis is responsible for approximately 70% of cases of large pericardial effusion and most cases of constrictive pericarditis in developing countries, where most of the world's population live. However, in industrialized countries, tuberculosis accounts for only 4% of cases of pericardial effusion and an even smaller proportion of instances of constrictive pericarditis. Tuberculous pericarditis is a dangerous disease with a mortality of 17% to 40%; constriction occurs in a similar proportion of cases after tuberculous pericardial effusion. Early diagnosis and institution of appropriate therapy are critical to prevent mortality. A definite or proven diagnosis is based on demonstration of tubercle bacilli in pericardial fluid or on histologic section of the pericardium. A probable or presumed diagnosis is based on proof of tuberculosis elsewhere in a patient with otherwise unexplained pericarditis, a lymphocytic pericardial exudate with elevated biomarkers of tuberculous infection, and/or appropriate response to a trial of antituberculosis chemotherapy. Treatment consists of 4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months regardless of HIV status. It is uncertain whether adjunctive corticosteroids are effective in reducing mortality or pericardial constriction, and their safety in HIV-infected patients has not been established conclusively. Surgical resection of the pericardium is indicated for those with calcific constrictive pericarditis or with persistent signs of constriction after a 6 to 8 week trial of antituberculosis treatment in patients with noncalcific constrictive pericarditis.
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MESH Headings
- AIDS-Related Opportunistic Infections/complications
- AIDS-Related Opportunistic Infections/diagnosis
- AIDS-Related Opportunistic Infections/drug therapy
- AIDS-Related Opportunistic Infections/epidemiology
- AIDS-Related Opportunistic Infections/microbiology
- AIDS-Related Opportunistic Infections/surgery
- Adrenal Cortex Hormones/therapeutic use
- Antitubercular Agents/therapeutic use
- Echocardiography
- Electrocardiography
- Humans
- Mycobacterium tuberculosis
- Pericardial Effusion/drug therapy
- Pericardial Effusion/microbiology
- Pericardial Effusion/pathology
- Pericardial Effusion/surgery
- Pericardiectomy
- Pericardiocentesis
- Pericarditis, Constrictive/drug therapy
- Pericarditis, Constrictive/microbiology
- Pericarditis, Constrictive/pathology
- Pericarditis, Constrictive/surgery
- Pericarditis, Tuberculous/complications
- Pericarditis, Tuberculous/diagnosis
- Pericarditis, Tuberculous/drug therapy
- Pericarditis, Tuberculous/epidemiology
- Pericarditis, Tuberculous/microbiology
- Pericarditis, Tuberculous/surgery
- Treatment Outcome
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Affiliation(s)
- Faisal F Syed
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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20
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Croome KP, Landis MS, Bach D, Chu MWA, McKenzie N. Cystic tuberculous constrictive pericarditis. CMAJ 2007; 177:148. [PMID: 17638949 PMCID: PMC1913129 DOI: 10.1503/cmaj.061494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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21
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Goyal S, Lim KT, Yap CH, Ryan EW, Mohajeri M. Chronic constrictive pericarditis: is tuberculosis still a cause? Med J Aust 2005; 182:353. [PMID: 15954236 DOI: 10.5694/j.1326-5377.2005.tb06736.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Burgess LJ. Biochemical analysis of pleural, peritoneal and pericardial effusions. Clin Chim Acta 2004; 343:61-84. [PMID: 15115678 DOI: 10.1016/j.cccn.2004.02.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Revised: 01/30/2004] [Accepted: 02/02/2004] [Indexed: 02/01/2023]
Abstract
Body fluids other than blood, urine and cerebrospinal fluid are often submitted for biochemical analysis. Of these, pleural, peritoneal and pericardial fluids are the most common. Laboratory tests are a useful tool to assess the aetiology, pathophysiology and subsequent treatment of effusions. A wide range of biochemical tests may be requested. This review critically examines the various analytes that have been used to investigate these body fluids.
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Affiliation(s)
- L J Burgess
- TREAD Research/Cardiology Unit, Stellenbosch University, P.O. Box 19174, Tygerberg 7505, Parow, South Africa.
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23
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Burgess LJ, Reuter H, Carstens ME, Taljaard JJF, Doubell AF. The use of adenosine deaminase and interferon-gamma as diagnostic tools for tuberculous pericarditis. Chest 2002; 122:900-5. [PMID: 12226030 DOI: 10.1378/chest.122.3.900] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Traditional diagnostic tests for pericardial tuberculosis (TB) are insensitive and often require long culture periods, and this has led to more emphasis being placed on biochemical tests such as the pericardial adenosine deaminase (ADA) test. However, controversy exists as to its diagnostic utility. In addition, the use of interferon (IFN)-gamma, which is a reliable indicator of pleural and peritoneal TB, has not been explored in pericardial effusions. We investigated ADA and IFN-gamma levels in pericardial effusions of different etiologies. METHODS AND RESULTS A prospective study was carried out from February 1995 to February 1998 at Tygerberg Hospital (South Africa), with pericardial taps being performed under echocardiographic guidance. During this period, 110 consecutive patients presenting with large pericardial effusions were included in the study. Diagnoses were made according to predetermined criteria, and they included TB (n = 64), malignancy (n = 12), nontuberculous infections (n = 5), other effusions (n = 19), and effusions of uncertain origin (n = 10). The median ADA level in the tuberculous group was 71.7 U/L (range, 10.3 to 303.6 U/L), which was significantly higher than that in any other group (p < 0.05). With a cutoff level for ADA activity of 30 U/L, sensitivity was 94%, specificity was 68%, and positive predictive value was 80%. IFN-gamma levels were determined in 30 subjects. The median IFN-gamma concentration in the tuberculous group was > 1,000 pg/L, which was significantly higher than in any other diagnostic group (p < 0.0005). A cutoff value of 200 pg/L for IFN-gamma resulted in a sensitivity and specificity of 100% for the diagnosis of pericardial TB. CONCLUSION Pericardial fluid levels of ADA and IFN-gamma are useful in the diagnosis of tuberculous pericarditis.
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Affiliation(s)
- Lesley J Burgess
- Department of Cardiology, Tygerberg Hospital and University of Stellenbosch, South Africa.
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24
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Safdar A, Humphery S, Harding S, Close T. Clinical microbiological case: cardiac tamponade due to hemorrhagic pericarditis in a non-immunocompromised woman from south-eastern United States. Clin Microbiol Infect 2002. [DOI: 10.1046/j.1469-0691.2002.00420.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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Feng YH, Chou MT, Hsu JJ, Chuang SS. Ascites and leg edema as the first manifestations of tuberculous effusive constrictive pericarditis. Int J Cardiol 2002; 82:55-7. [PMID: 11786158 DOI: 10.1016/s0167-5273(01)00555-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Kim HY, Song KS, Goo JM, Lee JS, Lee KS, Lim TH. Thoracic sequelae and complications of tuberculosis. Radiographics 2001; 21:839-58; discussion 859-60. [PMID: 11452057 DOI: 10.1148/radiographics.21.4.g01jl06839] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary tuberculosis is caused by Mycobacterium tuberculosis when droplet nuclei laden with bacilli are inhaled. In accordance with the virulence of the organism and the defenses of the host, tuberculosis can occur in the lungs and in extrapulmonary organs. A variety of sequelae and complications can occur in the pulmonary and extrapulmonary portions of the thorax in treated or untreated patients. These can be categorized as follows: (a) parenchymal lesions, which include tuberculoma, thin-walled cavity, cicatrization, end-stage lung destruction, aspergilloma, and bronchogenic carcinoma; (b) airway lesions, which include bronchiectasis, tracheobronchial stenosis, and broncholithiasis; (c) vascular lesions, which include pulmonary or bronchial arteritis and thrombosis, bronchial artery dilatation, and Rasmussen aneurysm; (d) mediastinal lesions, which include lymph node calcification and extranodal extension, esophagomediastinal or esophagobronchial fistula, constrictive pericarditis, and fibrosing mediastinitis; (e) pleural lesions, which include chronic empyema, fibrothorax, bronchopleural fistula, and pneumothorax; and (f) chest wall lesions, which include rib tuberculosis, tuberculous spondylitis, and malignancy associated with chronic empyema. These varieties of radiologic manifestations can mimic other disease entities. Therefore, recognition and understanding of the radiologic manifestations of the thoracic sequelae and complications of tuberculosis are important to facilitate diagnosis.
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Affiliation(s)
- H Y Kim
- Department of Radiology, Ewha Women's University Mokdong Hospital, Seoul, Korea
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27
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Gregory AK, Connery CP, Anagnostopoulos CE. A late complication of tuberculous pericarditis after partial pericardial resection. Ann Thorac Surg 1998; 65:542-4. [PMID: 9485265 DOI: 10.1016/s0003-4975(97)01358-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tuberculous pericarditis is estimated to occur in 1% to 2% of cases of pulmonary tuberculosis. Despite adequate therapy, a subset of patients may eventually require pericardiectomy. Incomplete pericardial resections are associated with an increased incidence of late complications. We report a cutaneous sinus tract communicating with residual pericardium and a retrosternal abscess cavity 11 years after partial pericardial resection.
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Affiliation(s)
- A K Gregory
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10025, USA
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28
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 19-1997. A 57-year-old man with a bloody pericardial effusion. N Engl J Med 1997; 336:1812-9. [PMID: 9187073 DOI: 10.1056/nejm199706193362508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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29
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Abstract
OBJECTIVE To identify features which predict the subsequent development of constrictive pericarditis from acute or subacute tuberculous (TB) pericarditis. SETTING Tertiary referral centre, chest hospital. PATIENTS The records of 16 consecutive patients in whom acute or subacute TB pericarditis was diagnosed between 1988 and 1990 at a chest hospital were reviewed. These records included a follow up of at least 12 months. RESULTS During a follow up of 14.2 (12-30) months, 8 patients had constrictive pericarditis diagnosed by cardiac catheterisation or by inspection at the time of operation (group A). There was no evidence of constriction in the other eight patients (group B). There was no significant difference between the two groups in the type or duration of symptoms of TB pericarditis before admission or the volume and characteristics of pericardial fluid obtained at hospital admission. Clinical features of cardiac tamponade on admission correlated closely with the subsequent development of constrictive pericarditis requiring pericardectomy (7/8 v 2/8; P = 0.01), despite the fact that the signs of tamponade resolved completely after pericardiocentesis. CONCLUSION The findings suggest that cardiac tamponade in the early clinical stage of TB pericarditis is the most predictive factor of subsequent constrictive pericarditis. The degree of fibrosis of pericardium when treatment starts may be the most important determinant of whether or not constriction develops.
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Affiliation(s)
- P K Suwan
- Cardiology Department, Central Chest Hospital, Nonthaburi, Thailand
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30
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Abter EIM, Schaening O, Barbour RL, Lutwick LI. Tuberculosis in the adult. Tuberculosis (Edinb) 1995. [DOI: 10.1007/978-1-4899-2869-6_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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31
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32
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Seino Y, Ikeda U, Kawaguchi K, Yamamoto K, Sekiguchi H, Nakayama T, Takewaki S, Okubo A, Nagai R, Yazaki Y. Tuberculous pericarditis presumably diagnosed by polymerase chain reaction analysis. Am Heart J 1993; 126:249-51. [PMID: 8322681 DOI: 10.1016/s0002-8703(07)80044-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Y Seino
- Department of Cardiology, Jichi Medical School, Tochigi, Japan
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33
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 49-1990. A 47-year-old Cape Verdean man with pericardial disease. N Engl J Med 1990; 323:1614-24. [PMID: 2233951 DOI: 10.1056/nejm199012063232308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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34
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Long R, Younes M, Patton N, Hershfield E. Tuberculous pericarditis: long-term outcome in patients who received medical therapy alone. Am Heart J 1989; 117:1133-9. [PMID: 2711975 DOI: 10.1016/0002-8703(89)90873-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A conservative approach to operative intervention in the treatment of active tuberculous pericarditis was adopted and only 4 of 16 consecutive patients underwent pericardiectomy, all within 2 months of diagnosis. One patient died of constrictive pericarditis despite pericardiectomy, and one died of acute bronchopneumonia after 8 months of otherwise successful medical management. All 14 long-term survivors were reevaluated to exclude chronic constrictive pericarditis and other potential sequelae of tuberculous pericarditis. Reevaluation included physical examination, chest radiograph, electrocardiogram, M-mode and two-dimensional echocardiogram, computed tomography (CT) scan, and in patients less than or equal to 75 years of age, incremental cycle exercise to maximum oxygen consumption. None were found to have chronic constrictive pericarditis or convincing evidence of other recognized complications of tuberculous pericarditis. Our results suggest that when pericardiectomy is not required for the relief of cardiac compression during the acute phase of tuberculous pericarditis and patients are treated with medical therapy alone, an excellent long-term outcome may be anticipated.
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Affiliation(s)
- R Long
- Department of Medicine, University of Manitoba, Winnipeg, Canada
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35
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Abstract
Pericarditis is a common but frequently subclinical entity. There are a number of causes, including infection, systemic illness, cardiac disease, trauma, and neoplasm. Iatrogenic causes include surgery, cardiac instrumentation, irradiation, and medications. The clinical presentation varies, depending on the cause. Chest pain and dyspnea are characteristic complaints. A typical progression of ECG changes occurs during the course of acute pericarditis. These changes occasionally require differentiation from those of acute myocardial infarction or normal variant ST segment elevation. Echocardiography is the most sensitive technique for detecting the presence of pericardial effusion. In addition, a number of echocardiographic findings are characteristic of larger effusions and cardiac tamponade. Any form of pericarditis may lead to the development of cardiac tamponade. Malignant effusion is probably the most common single cause.
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Affiliation(s)
- G L Sternbach
- Department of Emergency Medicine, Stanford University Medical Center, California 94305
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36
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Cardiovascular Tuberculosis. Tuberculosis (Edinb) 1988. [DOI: 10.1007/978-1-4684-0305-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Abstract
The cases of 17 patients with tuberculous pericarditis were reviewed. Thirteen patients had effusive pericarditis, and 10 had surgical drainage of the effusion. No deaths were due to pericardial tamponade; this appears to be related to earlier recognition of major pericardial effusions by echocardiography. In 2 patients clinical evidence of pericardial constriction developed while they were on a regimen of therapy, and in another 2 patients, echocardiography revealed pericardial thickening after resolution of the effusion. A pericardial window is recommended for the short-term management of patients suspected of having tuberculous pericarditis with a major pericardial effusion by echocardiography. If a thickened pericardium is found during the window procedure, early pericardiectomy is strongly encouraged.
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38
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Abstract
Ninety-five consecutive patients with constrictive pericarditis that was documented at the time of surgery during 1970 to 1985 were reviewed. The etiologies included idiopathic (42%), postradiotherapy (31%), post-cardiac surgery (11%), postinfective (6%), connective tissue disease-related (4%), neoplastic (3%) uremic (2%), and sarcoidosis (1%). Post-cardiac surgery etiology was seen only after 1980, but constituted 29% of cases during 1980-1985. Postradiotherapy etiology occurred with equal incidence in 1980-1985 and in 1970-1980, but the interval from radiotherapy to presentation with constrictive pericarditis was longer in the more recent period (11 vs 4.75 years). Effusive constrictive pericarditis occurred in 24% overall with similar prevalence in all of the etiologic groups except the postsurgical cases, which were caused by noneffusive fibrous constrictive pericarditis in all instances. Operative mortality was 12% overall: It was lower in the idiopathic group (8%) and higher in the postradiotherapy group (21%). Thus postradiotherapy constrictive pericarditis continues to occur despite technical changes aimed at reducing its likelihood, but recent cases have a longer latent period: and postsurgical constrictive pericarditis has emerged as an important etiology.
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Palatianos GM, Thurer RJ, Kaiser GA. Comparison of effectiveness and safety of operations on the pericardium. Chest 1985; 88:30-3. [PMID: 4006552 DOI: 10.1378/chest.88.1.30] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A ten-year experience with operations on the pericardium in 71 consecutive patients was reviewed. The patients ranged in age from nine months to 75 years old. Fifty-three patients were operated upon for pericardial effusion and 14 for pericardial constriction. Sixty-seven patients had pericarditis: 21 of them underwent subxiphoid tube drainage; ten, limited pericardiectomy; and the remaining 36, extensive pericardiectomy. There were two trauma victims who underwent diagnostic pericardiotomy. Two patients underwent excision of pericardial cysts. There was one operative death during extensive pericardiectomy for constrictive tuberculous pericarditis. Thirty-day mortality was three of 21 patients after subxiphoid tube drainage, three of ten after limited pericardiectomy and five of 36 after extensive pericardiectomy. Postoperative complications consisted of pulmonary problems in four patients (two after pericardiectomy and two after extensive pericardiectomy), cardiac arrhythmia in one patient after tube drainage and postpericardiotomy syndrome in one patient after extensive pericardiectomy. Mean follow-up was 3.2 years. Recurrent pericardial effusion occurred in two patients; one had limited pericardiectomy but did not require reoperation and one had diagnostic pericardiotomy without drainage. Six patients with persistent postirradiation pericardial effusion were treated effectively with extensive pericardiotomy. Our experience indicates that subxiphoid tube drainage is effective for the treatment of pericardial effusion and safer than limited pericardiectomy, while extensive pericardiectomy is the operation of choice for pericardial constriction and radiation-related pericardial effusion.
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40
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Abstract
During the 36-month period from July, 1978, through July, 1981, 25 patients underwent a subxiphoid pericardial window procedure for diagnosis and therapy. Twelve patients were operated on for uremic pericarditis, 6 for malignancy, and 7 for etiological diagnosis of the pericarditis. All 12 patients with renal failure had enlarging effusions, despite aggressive dialysis. Eleven of the 12 are alive, free from recurrence, 3 to 36 months postoperatively. Six patients were operated on for suspected pericardial malignancy with hemodynamic compromise. Histological diagnosis was made from the pericardial tissue in all patients; only 1 patient lived more than 43 days following the procedure. In the group of 7 patients operated on for diagnosis, 4 were thought preoperatively to have tuberculous pericarditis. All 4 were treated with anti-tuberculosis chemotherapy and are asymptomatic, without evidence of calcification, 12 to 31 months postoperatively. This diverse group of patients demonstrates that the subxiphoid pericardial window is an effective approach for relief of uremic effusions and may adequately treat effusive tuberculous pericarditis when combined with multidrug chemotherapy. Patients with suspected malignant pericardial disease and hemodynamic compromise need to be carefully studied before an operative procedure is considered as a means of diagnosis and therapy.
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