Constrictive pericarditis is a relatively rare clinical manifestation nowadays. We present the case of an HIV-positive patient with constrictive calcified pericarditis due to an infection with Mycobacterium tuberculosis. Pericardectomie was performed. The therapeutical approach is discussed and the literature is reviewe

Balmer, Mary-Claude

Bohlmann, Michael K.

Carrel, Thierry P.

Eckstein, Friedrich S.

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Case reportConstrictive tuberculous pericarditis in a HIV-positive patientFriedrich S. Ecksteina,*, Michael K. Bohlmanna, Mary-Claude Balmerb, Thierry P. CarrelaaClinic for Cardiovascular Surgery, University Hospital, Inselspital, Berne, SwitzerlandbDepartment of Pathology, University Hospital, Inselspital, Berne, SwitzerlandReceived 13 November 2000; received in revised form 28 March 2001; accepted 28 March 2001AbstractConstrictive pericarditis is a relatively rare clinical manifestation nowadays. We present the case of an HIV-positive patient withconstrictive calci®ed pericarditis due to an infection with Mycobacterium tuberculosis. Pericardectomie was performed. The therapeuticalapproach is discussed and the literature is reviewed. q 2001 Elsevier Science B.V. All rights reserved.Keywords: Constrictive pericarditis; Tuberculosis; HIV; Cardiac surgery1. IntroductionConstrictive pericarditis is a relatively rare clinical mani-festation nowadays but may be caused by infectiousdiseases, radiation, rheumatoid disease and sarcoidosis ormay appear late following trauma or after cardiac surgery.We report an unusual case for Western countries of a HIV-positive patient with constrictive calci®ed tuberculous peri-carditis as stage of an advanced extrapulmonary tuberculo-sis.2. Materials and methodsA 37-year-old man from Angola was admitted to aperipheral hospital with fever and dyspnea. At clinicalexamination major ®ndings were enlarged axillary lymphnodes, and clinical signs of beginning right heart insuf®-ciency with visible congested jugular veins, abdominaldistension and tachycardia. Chest radiography did notshow any major pathologic ®ndings. Screening for allcommon infections in African patients revealed HIV disease(stage C3) and tuberculosis with a multiresistant mycobac-terium; the latter was diagnosed by a biopsy of a cervicallymph node. Echocardiography and computed tomography(CT) showed multiple masses adherent to the pericardiumwith a maximum size of 75 £ 43 mm leading to severecompression of the left and right ventricle (Fig. 1). Thepatient was treated with a triple antiviral (Lamivudin 150mg and Zidovudin 300 mg twice daily respectively, Efavir-enz 600 mg daily) combined with an anti-tuberculous ther-apy (Clarithromycine 500 mg twice daily, Ethambutol 900mg daily, Isoniazid 300 mg daily; Pyrazinamid 2000 mgdaily and Levo¯oxacine 250 mg daily). Steroid therapy(Prednisolon 50 mg daily) was added for 10 weeks to reducethe clinical symptoms. Viremia disappeared and the CD4 1count improved from 74/ml to 208/ml. Repeated CT scansand echocardiography showed slight increase of pericardialmasses with signs of liquefaction and central necrosis in themajor tuberculomas. To prevent impairment of the cardiactamponade on the development of a constrictive pericardi-tis, pericardectomy was found to be indicated. Median ster-notomy was performed and severe adhesions of thepericardium with the heart were released. This was followedby a slight rise in arterial (from 80 to 100 mmHg) anddecrease in central venous pressure (from 16 to 11mmHg). A majority of the tuberculomas could be comple-tely removed. Small parts of the tuberculomas had to be leftin situ because of pericardial in®ltration in the region ofboth phrenic nerves. Chest closure was performed in a stan-dard fashion.3. ResultsHistologic examination of the pericardium revealed gran-ulomatous in¯ammation with areas of necrosis and Langer-hans giant cell reaction. However no acid-fast bacilli couldbe detected by Ziehl±Neelsen staining. Therefore DNA wasextracted from paraf®n sections and ampli®ed by polymer-ase chain reaction (PCR) with the IS6110 primers (speci®cfor the Mycobacterium tuberculosis complex) and the speci-European Journal of Cardio-thoracic Surgery 19 (2001) 940±9421010-7940/01/$ - see front matter q 2001 Elsevier Science B.V. All rights reserved.PII: S1010-7940(01)00715-1www.elsevier.com/locate/ejcts* Corresponding author. Tel.: 141-31-6322111; fax: 141-31-6322919.E-mail address: friedrich.eckstein@insel.ch (F.S. Eckstein).®c 12-base pairs PCR product was detected by agarose gelelectrophoresis (Fig. 2). In comparison results were compa-tible with tuberculosis.The further postoperative course was uneventful. Thepatient was discharged from hospital under antiviral andtuberculostatic therapy. He is currently asymptomatic anddoing well while pursuing his normal daily activities.4. DiscussionConstrictive pericarditis is a chronic in¯ammatory processthat involves both ®brous and serous layers of the pericar-dium and that leads to pericardial thickening with consecu-tive compression of the ventricles. This results in impairmentof diastolic ®lling and reduces cardiac function [1]. Ourpatient did not exhibit all clinical signs of chronic pericarditisbut an impressive compression of both ventricles was seenduring the operation. Constrictive pericarditis is best treatedby pericardiectomy since cardiac tamponade may appearshortly. Hospital mortality after pericardectomy is low (upto 5 % [2] and long term results after the operation are good.Subtotal pericardiectomy from phrenic nerve to phrenicnerve as carried out in our patient has comparable results insurvival and freedom from reoperation [3].An increasing incidence of tuberculosis has beenobserved in many countries; this disease is now the leadinginfectious cause of death world wide, being responsible forthree million deaths annually (WHO, World Health Report2000, Geneva). In some non-industrialized African coun-tries as e.g. Malawi, there has been a dramatic increase incases of tuberculosis as well as changes in disease patternrelated to the HIV epidemic. The number of cases increasedfrom 657 in 1986 to 2,734 in 1995, and the proportion ofcases with extra-pulmonary tuberculosis rose from 11% in1986 to 33% in 1995. Of those who were tested, 72% ofadults with smear-positive pulmonary tuberculosis and 64%of children with tuberculosis were found to be HIV-seropo-sitive [4]. Therefore infection with HIV has emerged as themost important predisposing factor for developing overttuberculosis in people co-infected with Mycobacteriumtuberculosis. In these patients tuberculous pericardial effu-sion is a common problem and one of the major cardiaccomplications in the course of HIV [5] leading to cardiactamponade in few patients [6] that has to be drained.Surprisingly our patient did not develop major signs ofchronic tuberculous pericarditis except for dyspnea. Adju-vant therapy with steroids signi®cantly decreases the risk ofdeveloping constrictive pericarditis in the ®rst year afterdiagnosis of pericardial effusion [7]. Although steroidshad been introduced with constrictive pericarditis alreadypresent, our patient improved clinically from this therapy.The presented case demonstrates that the rare combina-tion for European countries of HIV-infection and tubercu-losis may be observed especially in patient from countrieswith high prevalence of these diseases. After diagnosisconstrictive pericarditis as a known complication of tuber-culous pericarditis was successfully treated by pericardiect-omy to prevent cardiac tamponade. Constrictive pericarditisin an HIV-patient was only found once [8] leading to theconclusion that young patients with classical clinical signsof tuberculosis should be screened for HIV. When clinicalsigns of possible pericardial and cardiac involvementappear, echocardiography or CT scan should be performedto exclude constrictive pericarditis.F.S. Eckstein et al. / European Journal of Cardio-thoracic Surgery 19 (2001) 940±942 941Fig. 1. CT showed multiple masses adherent to the pericardium leading tosevere compression of the left and right ventricle (arrow heads).Fig. 2. Gel electrophoretic analysis of PCR ampli®cation products, gener-ated with primers speci®c for IS 6110 and for b-actin (expected productsize: 150 bp and 250 bp).References[1] Kirklin JW, Barrat-Boyes BG. Cardiac Surgery. Second Edition. NewYork: Churchill Livingstone, 1993. pp. 1683±1693.[2] DeValeria PA, Baumgartner WA, Casale AS, Greene PS, Cameron DE,Gardner TJ, Gott VL, Watkins L, Reitz BA. Current indications, risks,and outcome after pericardiectomy. Ann Thorac Surg 1991;52(2):219±224[3] Nataf P, Cacoub P, Dorent R, Jault F, Bors V, Pavie A, Cabrol C,Gandjbakhch I. Results of subtotal pericardiectomy for constrictivepericarditis. Eur J Cardio-thorac Surg 1993;7(5):252±255.[4] Harries AD, Parry C, Nyongonya Mbewe L, Graham SM, Daley HM,Maher D, Salaniponi FM, Nyangulu DS. The pattern of tuberculosis inQueen Elizabeth Central Hospital, Blantyre, Malawi: 1986-1995. Int JTuberc Lung Dis 1997;1(4):346±351.[5] Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M. Humanimmunode®ciency virus-associated pericardial effusion: report of 40cases and review of the literature. Am Heart J 1999;137(3):516±521.[6] Dronda F, Suzacq C. Pericardial tuberculosis complicated with hearttamponade as presentation form of acquired immunode®ciencysyndrome. Rev Clin Esp 1997;197(7):502±506.[7] Chen KY, Liaw YS, Kao HL, Yang PC, Luh KT. Constrictive pericar-ditis in patients with tuberculous pericarditis. J Formos Med Assoc1999;98(9):599±605.[8] Hakim JG, Matenga JA, Siziya S. Myocardial dysfunction in humanimmunode®ciency virus infection: an echocardiographic study of 157patients in hospital in Zimbabwe. Heart 1996;76(2):161±165.F.S. Eckstein et al. / European Journal of Cardio-thoracic Surgery 19 (2001) 940±942942

Constrictive tuberculous pericarditis in a HIV-positive patient

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