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Alene KA, Hertzog L, Gilmour B, Clements ACA, Murray MB. Interventions to prevent post-tuberculosis sequelae: a systematic review and meta-analysis. EClinicalMedicine 2024; 70:102511. [PMID: 38434448 PMCID: PMC10907188 DOI: 10.1016/j.eclinm.2024.102511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
Background Tuberculosis (TB) remains a global public health challenge, causing substantial mortality and morbidity. While TB treatment has made significant progress, it often leaves survivors with post-TB sequelae, resulting in long-term health issues. Current healthcare systems and guidelines lack comprehensive strategies to address post-TB sequelae, primarily due to insufficient evidence. This systematic review and meta-analysis aimed to identify effective interventions for preventing post-TB sequelae. Methods A systematic search was conducted across four databases including PubMed, SCOPUS, Web of Science, and Cochrane Central Register of Controlled Trials from inception to September 22, 2023. Eligible studies reported interventions designed to prevent post-TB sequelae were included. A random effect meta-analysis was conducted where applicable, and heterogeneity between studies was evaluated visually using forest plots and quantitatively using an index of heterogeneity (I2). This study is registered with PROSPERO (CRD42023464392). Findings From the 2525 unique records screened, 25 studies involving 10,592 participants were included. Different interventions were evaluated for different outcomes. However, only a few interventions were effective in preventing post-TB sequelae. Rehabilitation programs significantly improved lung function (Hedges's g = 0.21; 95% confidence interval (CI): 0.03, 0.39) and prevented neurological sequelae (relative risk (RR) = 0.10; 95% CI: 0.02, 0.42). Comprehensive interventions and cognitive-behavioural therapy significantly reduced the risk of mental health disorders among TB survivors (Hedges's g = -1.89; 95% CI: -3.77, -0.01). In contrast, interventions targeting post-TB liver sequelae, such as vitamin A and vitamin D supplementation and hepatoprotective agents, did not show significant reductions in sequelae (RR = 0.90; 95% CI: 0.52, 1.57). Moreover, adjunctive therapies did not show a significant effect in preventing post-TB neurological sequelae (RR = 0.62, 95% CI: 0.31, 1.24). Interpretation Rehabilitation programs prevented post-TB lung, neurologic and mental health sequelae, while adjuvant therapies and other interventions require further investigation. Funding Healy Medical Research Raine Foundation, Curtin School of Population Health and the Australian National Health and Medical Research Council.
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Affiliation(s)
- Kefyalew Addis Alene
- School of Population Health, Faculty of Health Sciences, Curtin University, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Australia
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Lucas Hertzog
- School of Population Health, Faculty of Health Sciences, Curtin University, Australia
| | - Beth Gilmour
- School of Population Health, Faculty of Health Sciences, Curtin University, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Australia
| | | | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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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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Ntsekhe M. Pericardial Disease in the Developing World. Can J Cardiol 2023; 39:1059-1066. [PMID: 37201721 DOI: 10.1016/j.cjca.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023] Open
Abstract
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.
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Affiliation(s)
- Mpiko Ntsekhe
- The Division of Cardiology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
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5
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Tuberculosis of the Heart: A Diagnostic Challenge. Tomography 2022; 8:1649-1665. [PMID: 35894002 PMCID: PMC9326682 DOI: 10.3390/tomography8040137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis of the heart is relatively rare and presents a significant diagnostic difficulty for physicians. It is the leading cause of death from infectious illness. It is one of the top 10 leading causes of death worldwide, with a disproportionate impact in low- and middle-income nations. The radiologist plays a pivotal role as CMR is a non-invasive radiological method that can aid in identifying potential overlap and differential diagnosis between tuberculosis, mass lesions, pericarditis, and myocarditis. Regardless of similarities or overlap in observations, the combination of clinical and certain particular radiological features, which are also detected by comparison to earlier and follow-up CMR scans, may aid in the differential diagnosis. CMR offers a significant advantage over echocardiography for detecting, characterizing, and assessing cardiovascular abnormalities. In conjunction with clinical presentation, knowledge of LGE, feature tracking, and parametric imaging in CMR may help in the early detection of tuberculous myopericarditis and serve as a surrogate for endomyocardial biopsy resulting in a quicker diagnosis and therapy. This article aims to explain the current state of cardiac tuberculosis, the diagnostic utility of CMR in tuberculosis (TB) patients, and offer an overview of the various imaging and laboratory procedures used to detect cardiac tuberculosis.
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6
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Armstrong SM, Thavendiranathan P, Butany J. The pericardium and its diseases. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00021-9] [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: 10/17/2022] Open
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López-López JP, Posada-Martínez EL, Saldarriaga C, Wyss F, Ponte-Negretti CI, Alexander B, Miranda-Arboleda AF, Martínez-Sellés M, Baranchuk A. Tuberculosis and the Heart. J Am Heart Assoc 2021; 10:e019435. [PMID: 33733808 PMCID: PMC8174360 DOI: 10.1161/jaha.120.019435] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.
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Affiliation(s)
- José Patricio López-López
- Department of Medicine Fundación Oftalmológica de Santander (FOSCAL) Bucaramanga Colombia.,Instituto de Investigaciones Masira Universidad de Santander (UDES) Bucaramanga Colombia
| | | | - Clara Saldarriaga
- Department of Cardiology and Heart Failure Clinic Clínica Cardiovascular Santa MariaUniversidad of Antioquia Medellín Colombia
| | - Fernando Wyss
- Technology and Cardiovascular Service of Guatemala - Cardiosolutions Guatemala City Guatemala
| | | | - Bryce Alexander
- Division of Cardiology Kingston Health Science CenterQueen's University Kingston Canada
| | | | - Manuel Martínez-Sellés
- Servicio de Cardiología Hospital Universitario Gregorio MarañónCIBERCVUniversidad EuropeaUniversidad Complutense Madrid Spain
| | - Adrian Baranchuk
- Division of Cardiology Kingston Health Science CenterQueen's University Kingston Canada
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Naicker K, Ntsekhe M. Tuberculous pericardial disease: a focused update on diagnosis, therapy and prevention of complications. Cardiovasc Diagn Ther 2020; 10:289-295. [PMID: 32420111 DOI: 10.21037/cdt.2019.09.20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Kishendree Naicker
- Division of Cardiology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Mpiko Ntsekhe
- Division of Cardiology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
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Howlett P, Du Bruyn E, Morrison H, Godsent IC, Wilkinson KA, Ntsekhe M, Wilkinson RJ. The immunopathogenesis of tuberculous pericarditis. Microbes Infect 2020; 22:172-181. [PMID: 32092538 DOI: 10.1016/j.micinf.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Patrick Howlett
- National Heart & Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London, SW3 6LY, United Kingdom; Department of Medicine, University of Cape Town, Observatory 7925, South Africa.
| | - Elsa Du Bruyn
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Hazel Morrison
- The Jenner Institute, University of Oxford, Old Road Campus Research Build, Roosevelt Dr, Oxford OX3 7DQ, United Kingdom
| | - Isiguzo C Godsent
- National Heart & Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London, SW3 6LY, United Kingdom; Department of Medicine, Federal Teaching Hospital Abakaliki, Nigeria
| | - Katalin A Wilkinson
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa; Francis Crick Institute, 1 Midland Rd, London NW1 1AT, United Kingdom
| | - Mpiko Ntsekhe
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Robert J Wilkinson
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa; Francis Crick Institute, 1 Midland Rd, London NW1 1AT, United Kingdom; Department of Infectious Diseases, Imperial College London, W2 1PG, United Kingdom
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Kim MS, Chang SA, Kim EK, Choi JO, Park SJ, Lee SC, Park SW, Oh JK. The Clinical Course of Tuberculous Pericarditis in Immunocompetent Hosts Based on Serial Echocardiography. Korean Circ J 2020; 50:599-609. [PMID: 32096358 PMCID: PMC7321756 DOI: 10.4070/kcj.2019.0317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/26/2019] [Accepted: 12/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives In East Asia, tuberculous pericarditis still occurs in immunocompetent patients. We aimed to investigate clinical course of tuberculous pericarditis and the trends of echocardiographic parameters for constrictive pericarditis. Methods We retrospectively analyzed medical records of patients with tuberculous pericarditis between January 2010 and January 2017 in Samsung Medical Center. Treatment consists of the standard 4-drug anti-tuberculosis regimen for 6 months with or without corticosteroids. We performed echocardiography at initial diagnosis, 1, 3 and 6 months later. Results Total 50 cases with tuberculous pericarditis in immunocompetent patients were enrolled. Echocardiographic finding at initial diagnosis divided into 3 groups: 1) pericardial effusion only (n=28, 56.0%), 2) effusive constrictive pericarditis (n=10, 20.0%) and 3) constrictive pericarditis (n=12, 24.0%). The proportion of patients with constrictive pericarditis decreased gradually over time. After 6 months, only 5 patients still had constrictive pericarditis. Out of the 28 patients who initially presented with effusion alone, only one patient developed constrictive pericarditis. Echocardiographic parameters representing constrictive pericarditis gradually disappeared over the follow up period. Ventricular interdependency improved significantly from 1 month follow-up, whereas septal bounce and pericardial thickening were still observed after 6 months without significant constrictive physiology. Conclusions Tuberculous pericarditis with pericardial effusion without constrictive physiology is unlikely to develop into constrictive pericarditis in immunocompetent hosts, if treated with optimal anti-tuberculous medication and steroid therapy. Even though there were hemodynamic feature of constrictive pericarditis, more than 80% of the patients were improved from constrictive pericarditis.
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Affiliation(s)
- Min Sun Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung A Chang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Ji Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Chol Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae K Oh
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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Long B, Liang SY, Koyfman A, Gottlieb M. Tuberculosis: a focused review for the emergency medicine clinician. Am J Emerg Med 2019; 38:1014-1022. [PMID: 31902701 DOI: 10.1016/j.ajem.2019.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to diagnose and treat. OBJECTIVE This narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician. DISCUSSION TB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations. CONCLUSIONS TB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, United States; Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States
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12
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Otu A, Hashmi M, Mukhtar AM, Kwizera A, Tiberi S, Macrae B, Zumla A, Dünser MW, Mer M. The critically ill patient with tuberculosis in intensive care: Clinical presentations, management and infection control. J Crit Care 2018; 45:184-196. [PMID: 29571116 DOI: 10.1016/j.jcrc.2018.03.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
Tuberculosis (TB) is one of the top ten causes of death worldwide. In 2016, there were 490,000 cases of multi-drug resistant TB globally. Over 2 billion people have asymptomatic latent Mycobacterium tuberculosis infection. TB represents an important, but neglected management issue in patients presenting to intensive care units. Tuberculosis in intensive care settings may present as the primary diagnosis (active drug sensitive or resistant TB disease). In other patients TB may be an incidental co-morbid finding as previously undiagnosed sub-clinical or latent TB which may re-activate under conditions of stress and immunosuppression. In Sub-Saharan Africa, where co-infection with the human immunodeficiency virus and other communicable diseases is highly prevalent, TB is one of the most frequent clinical management issues in all healthcare settings. Acute respiratory failure, septic shock and multi-organ dysfunction are the most common reasons for intensive care unit admission of patients with pulmonary or extrapulmonary TB. Poor absorption of anti-TB drugs occurs in critically ill patients and worsens survival. The mortality of patients requiring intensive care is high. The majority of early TB deaths result from acute cardiorespiratory failure or septic shock. Important clinical presentations, management and infection control issues regarding TB in intensive care settings are reviewed.
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Affiliation(s)
- Akaninyene Otu
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria; National Aspergillosis Centre, University Hospital of South Manchester, Manchester, United Kingdom
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Ahmed M Mukhtar
- Department of Anesthesia and Intensive Care, Cairo University, Cairo, Egypt
| | - Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Simon Tiberi
- Division of Infection, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Bruce Macrae
- Department of Microbiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Alimudin Zumla
- Division of Infection and Immunity, University College London Medical School, and NIHR Biomedical Research Center at University College of London Hospitals, London, United Kingdom
| | - Martin W Dünser
- Department of Critical Care, University College of London Hospital, London, United Kingdom; Department of Anaesthesia and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria.
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences University of Witwatersrand, Johannesburg, South Africa
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13
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Executive Summary: Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2017; 63:853-67. [PMID: 27621353 DOI: 10.1093/cid/ciw566] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 01/02/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M Higashi
- Tuberculosis Control Section, San Francisco Department of Public Health, California
| | - Christine S Ho
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB and Lung Disease, Paris, France
| | | | | | | | - H Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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14
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Wiysonge CS, Ntsekhe M, Thabane L, Volmink J, Majombozi D, Gumedze F, Pandie S, Mayosi BM. Interventions for treating tuberculous pericarditis. Cochrane Database Syst Rev 2017; 9:CD000526. [PMID: 28902412 PMCID: PMC5618454 DOI: 10.1002/14651858.cd000526.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Mpiko Ntsekhe
- Groote Schuur HospitalDivision of CardiologyObservatory 7925Cape TownSouth Africa
| | - Lehana Thabane
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics50 Charlton Ave ERoom H325, St. Joseph's HealthcareHamiltonONCanadaL8N 4A6
| | - Jimmy Volmink
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Dumisani Majombozi
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Freedom Gumedze
- University of Cape TownDepartment of Statistical SciencesCape TownSouth Africa
| | - Shaheen Pandie
- University of Cape TownDepartment of MedicineCape TownSouth Africa
| | - Bongani M Mayosi
- University of Cape TownDepartment of MedicineCape TownSouth Africa
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15
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Aoyama R, Ishikawa J, Harada K, Tukada Y. Tuberculous pericarditis treated with steroid in a dialysis patient. BMJ Case Rep 2017; 2017:bcr-2017-220562. [DOI: 10.1136/bcr-2017-220562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Abstract
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.
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Affiliation(s)
- Arthur K Mutyaba
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, E17 Cardiac Clinic, New Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Mpiko Ntsekhe
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, E17 Cardiac Clinic, New Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
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17
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Liebenberg JJ, Dold CJ, Olivier LR. A prospective investigation into the effect of colchicine on tuberculous pericarditis. Cardiovasc J Afr 2017; 27:350-355. [PMID: 27965998 PMCID: PMC5412665 DOI: 10.5830/cvja-2016-035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 03/16/2016] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Tuberculous (TB) pericarditis carries significant mortality and morbidity rates, not only during the primary infection, but also as part of the granulomatous scar-forming fibrocalcific constrictive pericarditis so commonly associated with this disease. Numerous therapies have previously been investigated as adjuvant strategies in the prevention of pericardial constriction. Colchicine is well described in the treatment of various aetiologies of pericarditis. The aim of this research was to investigate the merit for the use of colchicine in the management of tuberculous pericarditis, specifically to prevent constrictive pericarditis. METHODS This pilot study was designed as a prospective, double-blinded, randomised, control cohort study and was conducted at a secondary level hospital in the Northern Cape of South Africa between August 2013 and December 2015. Patients with a probable or definite diagnosis of TB pericarditis were included (n = 33). Study participants with pericardial effusions amenable to pericardiocentesis underwent aspiration until dryness. All patients were treated with standard TB treatment and corticosteroids in accordance with the South African Tuberculosis Treatment Guidelines. Patients were randomised to an intervention and control group using a web-based computer system that ensured assignment concealment. The intervention group received colchicine 1.0 mg per day for six weeks and the control group received a placebo for the same period. Patients were followed up with serial echocardiography for 16 weeks. The primary outcome assessed was the development of pericardial constriction. Upon completion of the research period, the blinding was unveiled and data were presented for statistical analysis. RESULTS TB pericarditis was found exclusively in HIV-positive individuals. The incidence of pericardial constriction in our cohort was 23.8%. No demonstrable benefit with the use of colchicine was found in terms of prevention of pericardial constriction (p = 0.88, relative risk 1.07, 95% CI: 0.46-2.46). Interestingly, pericardiocentesis appeared to decrease the incidence of pericardial constriction. CONCLUSION Based on this research, the use of colchicine in TB pericarditis cannot be advised. Adjuvant therapy in the prevention of pericardial constriction is still being investigated and routine pericardiocentesis may prove to be beneficial in this regard.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Adult
- Anti-Inflammatory Agents/therapeutic use
- Antitubercular Agents/therapeutic use
- Coinfection
- Colchicine/therapeutic use
- Double-Blind Method
- Echocardiography, Doppler, Color
- Echocardiography, Doppler, Pulsed
- Female
- HIV Infections/diagnosis
- HIV Infections/epidemiology
- Humans
- Incidence
- Male
- Pericardial Effusion/microbiology
- Pericardial Effusion/therapy
- Pericardiocentesis
- Pericarditis, Constrictive/diagnostic imaging
- Pericarditis, Constrictive/epidemiology
- Pericarditis, Constrictive/microbiology
- Pericarditis, Constrictive/prevention & control
- Pericarditis, Tuberculous/diagnostic imaging
- Pericarditis, Tuberculous/drug therapy
- Pericarditis, Tuberculous/epidemiology
- Pericarditis, Tuberculous/microbiology
- Pilot Projects
- Prospective Studies
- Risk Factors
- South Africa/epidemiology
- Time Factors
- Treatment Outcome
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18
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Banks AZ, Corey GR. Myocarditis and Pericarditis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00050-2] [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: 11/24/2022] Open
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19
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Jung IY, Song YG, Choi JY, Kim MH, Jeong WY, Oh DH, Kim YC, Song JE, Kim EJ, Lee JU, Jeong SJ, Ku NS, Kim JM. Predictive factors for unfavorable outcomes of tuberculous pericarditis in human immunodeficiency virus-uninfected patients in an intermediate tuberculosis burden country. BMC Infect Dis 2016; 16:719. [PMID: 27899066 PMCID: PMC5129391 DOI: 10.1186/s12879-016-2062-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/23/2016] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- In Young Jung
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Young Goo Song
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Moo Hyun Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Woo Yong Jeong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Dong Hyun Oh
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Yong Chan Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Je Eun Song
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Eun Jin Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Ji Un Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - Su Jin Jeong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea.
| | - Nam Su Ku
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
| | - June Myung Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Republic of Korea
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20
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Amin-Beidokhty A, Norouzi Z, Amiri A, Almasian M, Azadi A, Kheirollahi AR. Pericardial tuberculosis with an emphasis on empiric therapy in endemic areas for tuberculosis (a case report). Int J Mycobacteriol 2016; 5:360-365. [PMID: 27847027 DOI: 10.1016/j.ijmyco.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/08/2016] [Indexed: 11/18/2022] Open
Abstract
Pericardial tuberculosis (TB) is rare, but has particularly severe complications and a high mortality rate when not treated. Prompt treatment of pericardial TB is important and can be life-saving. We report a 13-year-old girl with massive pericardial effusion and negative workup for TB, who was empirically treated with an excellent response.
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Affiliation(s)
- Arash Amin-Beidokhty
- Department of Cardiology, Lorestan University of Medical Sciences, Khorramabad, Lorestan, Iran
| | - Zeinab Norouzi
- Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Lorestan, Iran.
| | - Ali Amiri
- Lorestan University of Medical Sciences, Clinical Research Center, Ashayer Hospital, Khorramabad, Lorestan, Iran
| | - Mohammad Almasian
- School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Lorestan, Iran
| | - Abbas Azadi
- Department of Infectious Disease, Lorestan University of Medical Sciences, Khorramabad, Lorestan, Iran
| | - Abdol-Reza Kheirollahi
- Department of Urology, Urology and Nephrology Research Center, Lorestan University of Medical Sciences, Khorramabad, Lorestan, Iran
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21
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 684] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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22
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Cherian G, Uthaman B, Salama A, Habashy AG, Khan NA, Cherian JM. Tuberculous Pericardial Effusion: Features, Tamponade, and Computed Tomography. Angiology 2016; 55:431-40. [PMID: 15258689 DOI: 10.1177/000331970405500410] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The clinical features with particular reference to tamponade and mediastinal adenopathy were studied in tuberculous pericardial effusion. Tamponade is a frequent complication and the recognition of tuberculous etiology can be difficult. Involvement of the pericardium is mostly from mediastinal lymph nodes that have not been studied. This was a prospective cohort study. All patients had large effusions, and underwent pericardiocentesis and chest computed tomography. Patients with tuberculosis had specific therapy. Others with viral/idiopathic effusion served as controls for the computed tomography studies. There were 26 patients with tuberculosis: 18 had tamponade on echocardiography. All had symptoms. Fever (n=23) and dyspnea (n=20) were the most frequent presenting symptoms. Pericardial rub was heard in 14, and 3 had enlarged cervical or axillary nodes. Pulmonary tuberculosis was present in 6. Tuberculin skin test measured 17 ±3.3 mm. The biopsy specimen showed a granuloma in 22 of 24. All 26 had mediastinal lymph nodes >10 mm with a mean size of 19.5 ±8.6 mm that disappeared (81%) or regressed (19%) on treatment (p<0.001). Aortopulmonary nodes were most frequently enlarged (65.4%) and hilar the least. Three required pericardiectomy. At follow-up all were doing well. None with viral/idiopathic effusion had lymph node enlargement. Fever, dyspnea, and tamponade were frequent with tuberculosis. The prognosis was good with specific therapy. Mediastinal nodes were enlarged in all and only with tuberculosis and not with viral/idiopathic effusion. Nodes disappeared or regressed with treatment. In the appropriate clinical context, mediastinal lymph node enlargement on chest computed tomography along with a strongly positive skin test results could help in the diagnosis of a tuberculous etiology of pericardial effusion.
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Sotgiu G, Nahid P, Loddenkemper R, Abubakar I, Miravitlles M, Migliori GB. The ERS-endorsed official ATS/CDC/IDSA clinical practice guidelines on treatment of drug-susceptible tuberculosis. Eur Respir J 2016; 48:963-971. [DOI: 10.1183/13993003.01356-2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/14/2016] [Indexed: 11/05/2022]
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Patil DV, Sabnis GR, Phadke MS, Lanjewar CP, Mishra P, Kulkarni DV, Agrawal NB, Kerkar PG. Echocardiographic parameters in clinical responders to surgical pericardiectomy - A single center experience with chronic constrictive pericarditis. Indian Heart J 2016; 68:316-24. [PMID: 27316484 PMCID: PMC4912479 DOI: 10.1016/j.ihj.2015.09.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 09/17/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Chronic constrictive pericarditis (CCP) is the end result of chronic inflammation of the pericardium. Developing countries continue to face a significant burden of CCP secondary to tuberculous pericarditis. Surgical pericardiectomy offers potential cure. However, there is paucity of echocardiography data in post-pericardiectomy patients vis-a-vis their clinical status. We studied the changes in multiple echocardiographic parameters in these patients before and after pericardiectomy. METHODS Twenty-three patients (14 men, 9 women) who underwent pericardiectomy for CCP in the last 5 years (from January 2009 to December 2014) were subjected to detailed clinical and echocardiographic evaluation during the study period (between June 2013 and December 2014). Patients with residual symptoms of NYHA class II and below were considered as 'responders'. The data thus obtained were compared to the pre-operative parameters. RESULTS After pericardiectomy, the incidence of vena caval congestion decreased from 100% to 15% (p<0.001). There was significant reduction in the mean left atrial size from 39.33±10.52mm to 34.45±10.08mm (p<0.001) and also the ratio of left atrium to aortic annulus from 1.93 to 1.69 (p<0.001) among 'responders' to pericardiectomy. Septal bounce was observed to persist in 5 (25%) patients after pericardiectomy. There was significant respiratory variation of 39.23±15.11% in the mitral E velocity before pericardiectomy. After pericardiectomy, this variation reduced to 14.43±7.76% (p<0.001). There was also significant reduction in the respiratory variation in tricuspid E velocities from 31.33±18.81% to 17.35±16.26% (p<0.001). After pericardiectomy, the mean ratio of mitral annular velocities, medial e': lateral e', reduced from 1.08 to 0.87 (p<0.03). The phenomenon of 'annulus reversus' was found to persist in 6 'responders', thereby reflecting a 50% reduction in its incidence after pericardiectomy (p<0.001). The ratio of mitral E to medial e' (E/e') increased from 4.21±1.35 before pericardiectomy to 6.91±2.62 after pericardiectomy (p=0.001). CONCLUSION Among clinical responders to surgical pericardiectomy, echocardiographic assessment revealed a significant reduction in vena caval congestion, LA size, ratio of LA to aortic annulus, septal bounce, respiratory variation in mitral and tricuspid E velocities, mitral annular medial e' and the phenomenon of annulus reversus. Also, there was a significant rise in minimum tricuspid and mitral E velocities and the E/e' ratio.
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Affiliation(s)
- Devendra V Patil
- Department of Cardiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India.
| | - Girish R Sabnis
- Department of Cardiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Milind S Phadke
- Department of Cardiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Charan P Lanjewar
- Department of Cardiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Prashant Mishra
- Department of Cardiovascular and Thoracic Surgery, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Dwarkanath V Kulkarni
- Department of Cardiovascular and Thoracic Surgery, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Nandkishor B Agrawal
- Department of Cardiovascular and Thoracic Surgery, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Prafulla G Kerkar
- Department of Cardiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
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Pollett S, Banner P, O’Sullivan MVN, Ralph AP. Epidemiology, Diagnosis and Management of Extra-Pulmonary Tuberculosis in a Low-Prevalence Country: A Four Year Retrospective Study in an Australian Tertiary Infectious Diseases Unit. PLoS One 2016; 11:e0149372. [PMID: 26963244 PMCID: PMC4786131 DOI: 10.1371/journal.pone.0149372] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Extra-pulmonary tuberculosis (EPTB) is relatively neglected and increasing in incidence, in comparison to pulmonary tuberculosis (PTB) in low-burden settings. It poses particular diagnostic and management challenges. We aimed to determine the characteristics of EPTB in Western Sydney, Australia, and to conduct a quality assurance investigation of adherence to guidelines among Infectious Diseases (ID) practitioners managing EPTB cases. METHODS All adult EPTB cases managed by a large ID service during 01/01/2008-31/12/2011 were eligible for inclusion in the retrospective review. Data were extracted from patient medical records on demographic, diagnostic, clinical and management details, and on clinician adherence to local and international TB guidelines. RESULTS 129 cases managed by the ID service were identified, with files available for 117. 98 cases were managed by the Respiratory service and were excluded. 98.2%(112/114) had been born in a country other than Australia. HIV status was tested or previously known in 97 people, and positive in 4 (4%). Microbiological confirmation was obtained in 68/117 (58.1%), an additional 24 had histopathological findings considered confirmatory (92/117, 78.6%), with the remainder diagnosed on clinical and/or radiological grounds. Median time to diagnosis post-migration from a high TB-burden country was 5 years (range 0-41). 95 cases were successfully treated, 11 cases defaulted, refused therapy or transferred, 2 cases relapsed and outcomes unknown or pending in 9 cases. No deaths occurred in the sample analysed. Clinician adherence to guidelines was high, but with scope for improvement in offering testing for co-infections, performing eye checks, monitoring blood glucose in patients receiving adjunctive corticosteroids, and considering drug interactions. CONCLUSIONS Despite excellent TB outcomes in this setting, the low proportion of cases with susceptibility data is worrying in this era of increasing drug resistance, and illustrates the diagnostic difficulties faced even in a well-resourced setting. Vigilance for EPTB needs to remain high in those moving from high prevalence countries to Australia, even decades after immigration.
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Affiliation(s)
- Simon Pollett
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | | | - Matthew V. N. O’Sullivan
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology, Westmead, Sydney, NSW, Australia
| | - Anna P. Ralph
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Department of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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The Pericardium and Its Diseases. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00015-x] [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: 11/19/2022] Open
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Critchley JA, Orton LC, Pearson F. Adjunctive steroid therapy for managing pulmonary tuberculosis. Cochrane Database Syst Rev 2014; 2014:CD011370. [PMID: 25387839 PMCID: PMC6532561 DOI: 10.1002/14651858.cd011370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tuberculosis causes approximately 8.6 million disease episodes and 1.3 million deaths worldwide per year. Although curable with standardized treatment, outcomes for some forms of tuberculosis are improved with adjunctive corticosteroid therapy. Whether corticosteroid therapy would be beneficial in treating people with pulmonary tuberculosis is unclear. OBJECTIVES To evaluate whether adjunctive corticosteroid therapy reduces mortality, accelerates clinical recovery or accelerates microbiological recovery in people with pulmonary tuberculosis. SEARCH METHODS We identified studies indexed from 1966 up to May 2014 by searching: Cochrane Infectious Diseases Group's trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and LILACS using comparative search terms. We handsearched reference lists of all identified studies and previous reviews and contacted relevant researchers, organizations and companies to identify grey literature. SELECTION CRITERIA Randomized controlled trials and quasi-randomized control trials of recognized antimicrobial combination regimens and corticosteroid therapy of any dose or duration compared with either no corticosteroid therapy or placebo in people with pulmonary tuberculosis were included. DATA COLLECTION AND ANALYSIS At least two investigators independently assessed trial quality and collected data using pre-specified data extraction forms. Findings were reported as narrative or within tables. If appropriate, Mantel-Haenszel meta-analyses models were used to calculate risk ratios. MAIN RESULTS We identified 18 trials, including 3816 participants, that met inclusion criteria. When compared to taking placebo or no steroid, corticosteroid use was not shown to to reduce all-cause mortality, or result in higher sputum conversion at 2 months or at 6 months (mortality: RR 0.77, 95%CI 0.51 to 1.15, 3815 participants, 18 studies, low quality evidence; sputum conversion at 2 months RR 1.03, 95%CI 0.97 to 1.09, 2750 participants, 12 studies; at 6 months; RR1.01, 95%CI 1.01, 95%CI 0.98 to 1.04, 2150 participants, 9 studies, both low quality evidence). However, corticosteroid use was found to increase weight gain (data not pooled, eight trials, 1203 participants, low quality evidence), decrease length of hospital stay (data not pooled, three trials, participants 379, very low quality of evidence) and increase clinical improvement within one month (RR 1.16, 95% CI 1.09 to 1.24; five trials, 497 participants, low quality evidence). AUTHORS' CONCLUSIONS It is unlikely that adjunctive corticosteroid treatment provides major benefits for people with pulmonary tuberculosis. Short term clinical benefits found did not appear to be maintained in the long term. However, evidence available to date is of low quality. In order to evaluate whether adjunctive corticosteroids reduce mortality, or accelerate clinical or microbiological recovery in people with pulmonary tuberculosis further large randomized control trials sufficiently powered to detect changes in such outcomes are needed.
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Affiliation(s)
- Julia A Critchley
- St George's, University of LondonPopulation Health Sciences InstituteCranmer TerraceLondonUKSW17 0RE
| | - Lois C Orton
- University of LiverpoolSchool of Population, Community and Behavioural SciencesDivision of Public HealthWhelan Building, Brownlow HillLiverpoolUKL69 3GB
| | - Fiona Pearson
- St George's, University of LondonPopulation Health Sciences InstituteCranmer TerraceLondonUKSW17 0RE
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Mayosi BM, Ntsekhe M, Bosch J, Pandie S, Jung H, Gumedze F, Pogue J, Thabane L, Smieja M, Francis V, Joldersma L, Thomas KM, Thomas B, Awotedu AA, Magula NP, Naidoo DP, Damasceno A, Chitsa Banda A, Brown B, Manga P, Kirenga B, Mondo C, Mntla P, Tsitsi JM, Peters F, Essop MR, Russell JBW, Hakim J, Matenga J, Barasa AF, Sani MU, Olunuga T, Ogah O, Ansa V, Aje A, Danbauchi S, Ojji D, Yusuf S. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis. N Engl J Med 2014; 371:1121-30. [PMID: 25178809 PMCID: PMC4912834 DOI: 10.1056/nejmoa1407380] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Tuberculous pericarditis is associated with high morbidity and mortality even if antituberculosis therapy is administered. We evaluated the effects of adjunctive glucocorticoid therapy and Mycobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis. METHODS Using a 2-by-2 factorial design, we randomly assigned 1400 adults with definite or probable tuberculous pericarditis to either prednisolone or placebo for 6 weeks and to either M. indicus pranii or placebo, administered in five injections over the course of 3 months. Two thirds of the participants had concomitant human immunodeficiency virus (HIV) infection. The primary efficacy outcome was a composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. RESULTS There was no significant difference in the primary outcome between patients who received prednisolone and those who received placebo (23.8% and 24.5%, respectively; hazard ratio, 0.95; 95% confidence interval [CI], 0.77 to 1.18; P=0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (25.0% and 24.3%, respectively; hazard ratio, 1.03; 95% CI, 0.82 to 1.29; P=0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (4.4% vs. 7.8%; hazard ratio, 0.56; 95% CI, 0.36 to 0.87; P=0.009) and hospitalization (20.7% vs. 25.2%; hazard ratio, 0.79; 95% CI, 0.63 to 0.99; P=0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer (1.8% vs. 0.6%; hazard ratio, 3.27; 95% CI, 1.07 to 10.03; P=0.03, and 1.8% vs. 0.5%; hazard ratio, 3.69; 95% CI, 1.03 to 13.24; P=0.03, respectively), owing mainly to an increase in HIV-associated cancer. CONCLUSIONS In patients with tuberculous pericarditis, neither prednisolone nor M. indicus pranii had a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. (Funded by the Canadian Institutes of Health Research and others; IMPI ClinicalTrials.gov number, NCT00810849.).
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Wilkinson RJ. Host-directed therapies against tuberculosis. THE LANCET RESPIRATORY MEDICINE 2014; 2:85-7. [DOI: 10.1016/s2213-2600(13)70295-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Syed FF, Ntsekhe M, Gumedze F, Badri M, Mayosi BM. Myopericarditis in tuberculous pericardial effusion: prevalence, predictors and outcome. Heart 2013; 100:135-9. [DOI: 10.1136/heartjnl-2013-304786] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
The human immunodeficiency virus (HIV) has altered the epidemiology, clinical manifestations, treatment considerations and natural history of tuberculous (TB) pericarditis with significant implications for clinicians. The caseload of TB pericarditis has risen sharply in TB endemic areas of the world where co-infection with HIV is common. Furthermore, TB is the cause in greater than 85 % of cases of pericardial effusion in HIV-infected cohorts. In the absence of HIV, the morbidity of TB pericarditis is primarily related to the ferocity of the immune response to TB antigens within the pericardium. In patients with HIV, because TB pericarditis more often occurs as part of a disseminated process, the infection itself has a greater impact on the morbidity and mortality. HIV-associated TB pericarditis is a more aggressive disease with a greater degree of myocardial involvement. Patients have larger pericardial effusions with more frequent hemodynamic compromise and more significant ST segment changes in the electrocardiogram. HIV alters the natural history and outcomes of TB pericarditis. Immunocompromised participants appear less likely to develop constrictive pericarditis and have a significantly higher mortality compared with their immunocompetent counterparts. Finally co-infection with HIV has resulted in a number of areas of uncertainty. The mechanisms of myocardial dysfunction are unclear, new methods of improving the yield of TB culture and establishing a rapid bacterial diagnosis remain a major challenge, the optimal duration of anti-TB therapy has yet to be established, and the role of corticosteroids has yet to be resolved.
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Affiliation(s)
- Mpiko Ntsekhe
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, E-17 New Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa.
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Critchley JA, Young F, Orton L, Garner P. Corticosteroids for prevention of mortality in people with tuberculosis: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2013; 13:223-37. [PMID: 23369413 DOI: 10.1016/s1473-3099(12)70321-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effects of corticosteroids are systemic, but their benefits in tuberculosis are thought to be organ specific, with clinicians using them routinely to treat some forms of tuberculosis (such as meningitis), but not others. We aimed to assess the effects of steroids on mortality attributable to all forms of tuberculosis across organ systems. METHODS We did a systematic review and meta-analysis to estimate the efficacy of steroids for the prevention of mortality in all forms of tuberculosis, and to quantify heterogeneity in this outcome between affected organ systems. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Central Register of Controlled Trials, Medline, Embase, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) for studies published up to Sept 6, 2012, and checked reference lists of included studies and relevant reviews. We included all trials in people with tuberculosis in any organ system, with tuberculosis defined clinically or microbiologically. There were no restrictions by age, comorbidity, publication language, or type, dose, or duration of steroid treatment. We used the Mantel-Haenszel method to summarise mortality across trials. FINDINGS We identified 41 eligible trials, 18 of which assessed pulmonary tuberculosis. 20 of the 41 trials (including 13 of those for pulmonary tuberculosis) were done before the introduction of modern rifampicin-containing antituberculosis chemotherapy. Meta-analysis stratified by affected organ systems identified no heterogeneity; steroids reduced mortality by 17% (risk ratio [RR] 0·83, 95% CI 0·74-0·92; I(2) 0%), consistent across all organ groups. In a sensitivity analysis that only included trials that used rifampicin-containing regimens, the results were similar (RR 0·85, 95% CI 0·74-0·98; I(2) 21%). A sensitivity analysis in pulmonary tuberculosis that excluded trials with high potential risks of bias suggested a slight benefit, but the point estimate was closer to no effect and the difference was not significant (RR 0·93, 95% CI 0·60-1·44). INTERPRETATION Steroids could be effective in reducing mortality for all forms of tuberculosis, including pulmonary tuberculosis. However, further evidence is needed since few recent trials have assessed the effectiveness of corticosteroids in patients with pulmonary tuberculosis. FUNDING UK Department for International Development.
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Affiliation(s)
- Julia A Critchley
- Division of Population Health Sciences and Education, St George's, University of London, London, UK.
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Meintjes G, Skolimowska KH, Wilkinson KA, Matthews K, Tadokera R, Conesa-Botella A, Seldon R, Rangaka MX, Rebe K, Pepper DJ, Morroni C, Colebunders R, Maartens G, Wilkinson RJ. Corticosteroid-modulated immune activation in the tuberculosis immune reconstitution inflammatory syndrome. Am J Respir Crit Care Med 2012; 186:369-77. [PMID: 22700860 DOI: 10.1164/rccm.201201-0094oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE HIV-tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an immunopathological reaction to mycobacterial antigens induced by antiretroviral therapy. Prednisone reduces morbidity in TB-IRIS, but the mechanisms are unclear. OBJECTIVES To determine the effect of prednisone on the inflammatory response in TB-IRIS (antigen-specific effector T cells, cytokines, and chemokines). METHODS Blood was taken from participants in a randomized placebo-controlled trial of prednisone for TB-IRIS, at 0, 2, and 4 weeks. Participants received prednisone at a dosage of 1.5 mg/kg/day for 2 weeks followed by 0.75 mg/kg/day for 2 weeks, or placebo at identical dosages. MEASUREMENTS AND MAIN RESULTS Analyses included IFN-γ enzyme-linked immunospot (ELISPOT), reverse transcription-polymerase chain reaction on peripheral blood mononuclear cells after restimulation with heat-killed Mycobacterium tuberculosis, Luminex multiplex cytokine analysis of corresponding tissue culture supernatants, and Luminex multiplex cytokine analysis of serum. Fifty-eight participants with TB-IRIS (31 receiving prednisone, 27 receiving placebo) were included. In serum, significant decreases in IL-6, IL-10, IL-12 p40, tumor necrosis factor-α, IFN-γ, and IFN-γ-induced protein-10 concentrations during prednisone, but not placebo, treatment were observed. No differences in ELISPOT responses comparing prednisone and placebo groups were shown in response to ESAT-6 (early secreted antigen target-6), Acr1, Acr2, 38-kD antigen, or heat-killed H37Rv M. tuberculosis. Purified protein derivative ELISPOT responses increased over 4 weeks in the prednisone group and decreased in the placebo group (P = 0.007). CONCLUSIONS The beneficial effects of prednisone in TB-IRIS appear to be mediated via suppression of predominantly proinflammatory cytokine responses of innate immune origin, not via a reduction of the numbers of antigen-specific T cells in peripheral blood.
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Affiliation(s)
- Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Achkar JM, Joseph G. Independent association of younger age with hemoptysis in adults with pulmonary tuberculosis. Int J Tuberc Lung Dis 2012; 16:897-902. [PMID: 22583746 DOI: 10.5588/ijtld.11.0758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The risk factors for mild to moderate hemoptysis in patients with pulmonary tuberculosis (PTB) are not entirely clear. OBJECTIVE To evaluate the independent association of risk factors with the occurrence of hemoptysis in PTB patients. DESIGN Cross-sectional study of adult patients newly diagnosed with microbiologically proven PTB in a New York City hospital. Patients were categorized into subjects with and without hemoptysis and compared using univariate analysis. Independent associations of variables with hemoptysis were estimated using multivariate logistic regression. RESULTS Of 194 subjects with PTB, 44 (23%) had hemoptysis. In univariate analysis, subjects with hemoptysis were significantly younger (P = 0.003), and more likely to be undocumented foreign-born (P = 0.038) compared to subjects without hemoptysis. In multivariate analysis, only younger age was independently associated with hemoptysis. This association was significant for a continuous decrease in age per year, or per decade (adjusted OR 1.59, P = 0.003). CONCLUSIONS Younger age is an independent risk factor for hemoptysis in PTB. It is conceivable that a stronger inflammatory response in younger than in older age could contribute to pulmonary pathogenesis and injury in PTB.
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Affiliation(s)
- J M Achkar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Marquez L, Starke JR. Diagnosis and management of TB in children: an update. Expert Rev Anti Infect Ther 2012; 9:1157-68. [PMID: 22114966 DOI: 10.1586/eri.11.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In recent years, several notable modifications have occurred in the management of TB infection and disease in children. First, we review new data related to infection, including alternative regimens for the treatment of latent TB, management of drug-resistant infection and preventive therapy in the context of HIV infection. Next, we summarize updated WHO guidelines for the treatment of TB in children, explore issues specific to the management of disease in HIV-infected children, and retreatment of TB, and review pediatric recommendations for the management of drug-resistant TB. Finally, we conclude with a discussion of adjunctive therapy and new drugs in development.
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Affiliation(s)
- Lucila Marquez
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
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Aslangul E, Le Jeunne C. Place des corticoïdes dans le traitement des infections. Presse Med 2012; 41:400-5. [DOI: 10.1016/j.lpm.2012.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 12/19/2011] [Accepted: 01/04/2012] [Indexed: 10/14/2022] Open
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Yoon SA, Hahn YS, Hong JM, Lee OJ, Han HS. Tuberculous pericarditis presenting as multiple free floating masses in pericardial effusion. J Korean Med Sci 2012; 27:325-8. [PMID: 22379347 PMCID: PMC3286783 DOI: 10.3346/jkms.2012.27.3.325] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 11/04/2011] [Indexed: 01/22/2023] Open
Abstract
Pericarditis is a rare manifestation of tuberculosis (Tb) in children. A 14-yr-old Korean boy presented with cardiac tamponade during treatment of pulmonary tuberculosis. He developed worsening anemia and persistent fever in spite of anti-tuberculosis medications. Echocardiography found free floating multiple discoid masses in the pericardial effusion. The masses and exudates were removed by pericardiostomy. The masses were composed of pink, amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes with numerous acid-fast bacilli, which were confirmed as Mycobacterium species by polymerase chain reaction. The persistent fever and anemia were controlled after pericardiostomy. This is the report of a unique manifestation of Tb pericarditis as free floating masses in the effusion with impending tamponade.
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Affiliation(s)
- Shin-Ae Yoon
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Youn-Soo Hahn
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jong Myeon Hong
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Ok-Jun Lee
- Department of Pathology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Heon-Seok Han
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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38
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Florián MC, Franco S, Santacruz D, Montoya KF. Pericarditis tuberculosa: presentación de un caso y revisión de la literatura. REVISTA COLOMBIANA DE CARDIOLOGÍA 2011. [DOI: 10.1016/s0120-5633(11)70200-5] [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] Open
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Heller T, Lessells RJ, Wallrauch C, Brunetti E. Tuberculosis pericarditis with cardiac tamponade: management in the resource-limited setting. Am J Trop Med Hyg 2010; 83:1311-4. [PMID: 21118941 PMCID: PMC2990051 DOI: 10.4269/ajtmh.2010.10-0271] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 06/16/2010] [Indexed: 11/16/2022] Open
Abstract
We report a case of human immunodeficiency virus-associated pericardial tuberculosis complicated by cardiac tamponade. Emergency management and subsequent therapeutic interventions are described and then discussed with particular focus on resource-limited settings. The paucity of evidence to support clinical decisions is emphasized and the need for well designed diagnostic and therapeutic studies is highlighted.
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Affiliation(s)
- Tom Heller
- Hlabisa Hospital, Hlabisa, KwaZulu-Natal, South Africa.
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Meintjes G, Wilkinson RJ, Morroni C, Pepper DJ, Rebe K, Rangaka MX, Oni T, Maartens G. Randomized placebo-controlled trial of prednisone for paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome. AIDS 2010; 24:2381-90. [PMID: 20808204 PMCID: PMC2940061 DOI: 10.1097/qad.0b013e32833dfc68] [Citation(s) in RCA: 248] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of antiretroviral therapy in resource-limited countries. We aimed to assess whether a 4-week course of prednisone would reduce morbidity in patients with paradoxical TB-IRIS without excess adverse events. DESIGN A randomized, double-blind, placebo-controlled trial of prednisone (1.5 mg/kg per day for 2 weeks then 0.75 mg/kg per day for 2 weeks). Patients with immediately life-threatening TB-IRIS manifestations were excluded. METHODS The primary combined endpoint was days of hospitalization and outpatient therapeutic procedures, which were counted as one hospital day. RESULTS One hundred and ten participants were enrolled (55 to each arm). The primary combined endpoint was more frequent in the placebo than the prednisone arm {median hospital days 3 [interquartile range (IQR) 0-9] and 0 (IQR 0-3), respectively; P = 0.04}. There were significantly greater improvements in symptoms, Karnofsky score, and quality of life (MOS-HIV) in the prednisone vs. the placebo arm at 2 and 4 weeks, but not at later time points. Chest radiographs improved significantly more in the prednisone arm at weeks 2 (P = 0.002) and 4 (P = 0.02). Infections on study medication occurred in more participants in prednisone than in placebo arm (27 vs. 17, respectively; P = 0.05), but there was no difference in severe infections (2 vs. 4, respectively; P = 0.40). Isolates from 10 participants were found to be resistant to rifampicin after enrolment. CONCLUSION Prednisone reduced the need for hospitalization and therapeutic procedures and hastened improvements in symptoms, performance, and quality of life. It is important to investigate for drug-resistant tuberculosis and other causes for deterioration before administering glucocorticoids.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South.
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41
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Porridge-like tuberculous cardiac tamponade: treatment difficulties in the Horn of Africa. Gen Thorac Cardiovasc Surg 2010; 58:276-8. [PMID: 20549456 DOI: 10.1007/s11748-009-0525-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Accepted: 08/16/2009] [Indexed: 10/19/2022]
Abstract
A 16-year-old boy was hospitalized for fever, chest pain, and cardiovascular collapse. Transthoracic echocardiography revealed a 30-mm circumferential echogenic "porridge-like" pericardial effusion with signs of cardiac tamponade. Tuberculosis (TB) was suspected because of its prevalence in Djibouti. Emergency pericardiocentesis was attempted, but only 10 ml of pericardial fluid was obtained. Subxiphoid pericardiotomy and drainage were then performed, and pericardial fibrinous pockets were surgically collapsed. Antituberculosis chemotherapy was given, and the pericardial effusion progressively disappeared without corticosteroids. The diagnosis of TB was subsequently confirmed by cultures of the pericardial fluid. A pericardial biopsy was normal. After 3 months of follow-up, there was no sign of constrictive pericarditis. Pericardiocentesis may fail in cases of advanced-stage fibrinous TB pericardial effusion. Thus, pericardiotomy with complete open draining is the only lifesaving procedure.
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42
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Luther VP, Bookstaver PB, Ohl CA. Corticosteroids in the treatment of hepatic tuberculosis: case report and review of the literature. ACTA ACUST UNITED AC 2010; 42:315-7. [PMID: 20092380 DOI: 10.3109/00365540903490034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The role of corticosteroid therapy in addition to anti-tuberculous agents in the treatment of hepatic tuberculosis is unclear. We describe a 54-y-old female with hepatic tuberculosis and worsening hepatitis after initiation of anti-tuberculosis therapy. She experienced considerable clinical improvement and ultimately a complete recovery upon the receipt of adjunctive corticosteroids.
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Affiliation(s)
- Vera P Luther
- Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
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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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45
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Goldberger ZD, Loge AS. Three's company: an unusual clue. Am J Med 2008; 121:774-6. [PMID: 18724966 DOI: 10.1016/j.amjmed.2008.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 01/14/2008] [Accepted: 01/14/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Zachary D Goldberger
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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46
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Abstract
Antimycobacterial chemotherapy is the mainstay of treatment for the majority of patients with genitourinary tuberculosis (GUTB). A large body of evidence from clinical trials suggests that short-course chemotherapy regimens, employing four drugs including rifampicin and pyrazinamide, achieve cure in most of the patients with tuberculosis (TB) and are associated with the lowest rates of relapse. Standard six-month regimens are adequate for the treatment of GUTB. Directly observed treatment, short-course (DOTS) is the internationally recommended comprehensive strategy to control TB, and directly observed treatment is just one of its five elements. DOTS cures not only the individual with TB but also reduces the incidence of TB as well as the prevalence of primary drug-resistance in the community. Corticosteroids have no proven role in the management of patients with GUTB. Errors in prescribing anti-TB drugs are common in clinical practice. Standardized treatment regimens at correct doses and assured completion of treatment have made DOTS the present-day standard of care for the management of all forms of TB including GUTB.
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Affiliation(s)
- Tamilarasu Kadhiravan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi - 110 608, India
| | - Surendra K. Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi - 110 608, India
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Ntsekhe M, Wiysonge CS, Gumedze F, Maartens G, Commerford PJ, Volmink JA, Mayosi BM. HIV infection is associated with a lower incidence of constriction in presumed tuberculous pericarditis: a prospective observational study. PLoS One 2008; 3:e2253. [PMID: 18523576 PMCID: PMC2386966 DOI: 10.1371/journal.pone.0002253] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 04/17/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pericardial constriction is a serious complication of tuberculous pericardial effusion that occurs in up to a quarter of patients despite anti-tuberculosis chemotherapy. The impact of human immunodeficiency virus (HIV) infection on the incidence of constrictive pericarditis following tuberculous pericardial effusion is unknown. METHODS AND RESULTS We conducted a prospective observational study to determine the association between HIV infection and the incidence of constrictive pericarditis among 185 patients (median age 33 years) with suspected tuberculous pericardial effusion. These patients were recruited consecutively between March and October 2004 on commencement of anti-tuberculosis treatment, from 15 hospitals in Cameroon, Nigeria and South Africa. Surviving patients (N = 119) were assessed for clinical evidence of constrictive pericarditis at 3 and 6 months of follow-up. Clinical features of HIV infection were present in 42 (35.2%) of the 119 patients at enrolment into the study. 66 of the 119 (56.9%) patients consented to HIV testing at enrolment. During the 6 months of follow-up, a clinical diagnosis of constrictive pericarditis was made in 13 of the 119 patients (10.9 %, 95% confidence interval [CI] 5.9-18%). Patients with clinical features of HIV infection appear less likely to develop constriction than those without (4.8% versus 14.3%; P = 0.08). None of the 33 HIV seropositive patients developed constriction, but 8 (24.2%, 95%CI 11.1-42.3%) of the 33 HIV seronegative patients did (P = 0.005). In a multivariate logistic regression model adjusting simultaneously for several baseline characteristics, only clinical signs of HIV infection were significantly associated with a lower risk of constriction (odd ratio 0.14, 95% CI 0.02-0.87, P = 0.035). CONCLUSIONS These data suggest that HIV infection is associated with a lower incidence of pericardial constriction in patients with presumed tuberculous pericarditis.
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Affiliation(s)
- Mpiko Ntsekhe
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles S. Wiysonge
- South African Cochrane Centre, Medical Research Council, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Jimmy A. Volmink
- South African Cochrane Centre, Medical Research Council, Cape Town, South Africa
- Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Bongani M. Mayosi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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48
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The use of adjunctive corticosteroids in the treatment of pericardial, pleural and meningeal tuberculosis: do they improve outcome? Respir Med 2008; 102:793-800. [PMID: 18407484 DOI: 10.1016/j.rmed.2008.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 01/24/2008] [Indexed: 02/08/2023]
Abstract
Tuberculosis remains a major cause of mortality and morbidity on a global scale. Effective anti-tuberculous chemotherapy has improved outcomes for individuals suffering from tuberculosis, although the disease often results in significant and permanent damage to organs. The use of adjunctive corticosteroid treatment has been studied with a view to demonstrating a reduction in inflammatory events that may improve outcomes for both mortality and morbidity. Cochrane reviews have summarized the evidence for adjunctive corticosteroids in the treatment of tuberculous pericarditis, meningitis and pleural effusion. These reviews have shown improved mortality for pericarditis and meningitis, but inconclusive effects for pericardial constriction and ongoing neurological disability. Rapid improvements in clinical parameters for pleural effusion were not supported by any lasting improved outcomes for these patients.
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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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50
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Domínguez-Castellano A, Del Arco A, Canueto-Quintero J, Rivero-Román A, Kindelán JM, Creagh R, Díez-García F. Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis. Enferm Infecc Microbiol Clin 2007; 25:519-34. [PMID: 17915111 DOI: 10.1157/13109989] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The therapeutic scheme for initial pulmonary tuberculosis recommended by the SAEI is as follows: Initial phase, isoniazid, rifampin and pyrazinamide given daily for 2 months. In HIV(+) patients and immigrants from areas with a rate of primary resistance to isoniazid > 4%, ethambutol should be added until susceptibility studies are available. Second phase (continuation phase): rifampin and isoniazid, given daily or intermittently for 4 months in the general population. HIV(+) patients (< or = 200 CD4) and culture-positive patients after 2 months of treatment should receive a 7-month continuation phase. A 6-month regimen is recommended for extrapulmonary tuberculosis, with the exception of tuberculous meningitis, which should be treated for a minimum of 12 months and bone/joint tuberculosis, treated for a minimum of 9 months. Treatment regimens for multidrug resistant tuberculosis are based on expert opinion. These would include a combination of still-useful first-line drugs, injectable agents, and alternative agents, such as quinolones. Patients who present a special risk of transmitting the disease or of non-adherence should be treated with directly observed therapy.
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