Pericarditis is a rare manifestation of tuberculosis and can be fatal. We describe a 15-year-old girl admitted for a large pericardial effusion. Subxiphoid pericardial biopsy was performed. Biopsy samples were positive for M. tuberculosis DNA by PCR, which confirmed the diagnosis of tuberculous pericarditis

Bolt, Roel J.

Rammeloo, Lukas A.

van Furth, A. Marceline

van Well, Gijs T. J

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SHORT REPORT
A 15-year-old girl with a large pericardial effusion
Roel J. Bolt & Lukas A. Rammeloo &
A. Marceline van Furth & Gijs T. J van Well
Received: 2 May 2007 /Accepted: 19 June 2007 /Published online: 18 August 2007
# Springer-Verlag 2007
Abstract Pericarditis is a rare manifestation of tuberculosis
and can be fatal. We describe a 15-year-old girl admitted for
a large pericardial effusion. Subxiphoid pericardial biopsy
was performed. Biopsy samples were positive for M.
tuberculosis DNA by PCR, which confirmed the diagnosis
of tuberculous pericarditis.
Keywords Tuberculosis . Pericarditis
Subxiphoidal biopsy . Corticosteroids
A 15-year-old girl was admitted with chest pain, progres-
sive shortness of breath, fever, nonproductive cough,
decreased appetite, weight loss, and fatigue. The patient
was born in Angola, but had lived in the Netherlands for
14 years. Seven months before admission she had traveled
to the Democratic Republic of Congo in Western Africa.
Her temperature was 39.7°C, her pulse 90 beats/min,
respiratory rate 28 breaths/min, and blood pressure 96/
58 mmHg. No enlarged lymph nodes were found. Soft
cardiac tones and a friction rub were noticed. The liver was
enlarged.
Laboratory results showed normal white blood cells and
platelets with a decreased hemoglobin (4.3 mmol/l). The
erythrocyte sedimentation rate was 60 mm/h.
A chest radiograph showed marked enlargement of the
cardiac silhouette with no other abnormalities. Echocardi-
ography revealed a large pericardial effusion containing
exudative debris and fibrin strands (Fig. 1). Extensive
laboratory studies for auto-immune diseases and infections,
including HIV, did not reveal the cause.
Under general anesthesia the pericardial fluid was
drained and a subxiphoid pericardial biopsy was performed.
The PCR for M. tuberculosis DNA was positive on the
pericardium, though not in the pericardial fluid. The patient
was treated with four anti-tuberculous drugs (isoniazide,
ethambutol, pyrazinamide, rifampicin) for 4 months and
two anti-tuberculous drugs for an additional 4 months.
Adjunctive treatment with predinisolone was tapered over a
12-week period. The patient completely recovered and did
not develop any signs of constrictive pericarditis. She was
followed up for more than 1 year and then discharged
because of uneventful recovery.
Discussion
Pericarditis is a rare manifestation of tuberculosis that can
be fatal and accounts for approximately 1–2% of all cases
Eur J Pediatr (2008) 167:811–812
DOI 10.1007/s00431-007-0559-z
R. J. Bolt
Department of Pediatrics, VU University Medical Center,
Amsterdam, The Netherlands
L. A. Rammeloo
Department of Pediatric Cardiology,
VU University Medical Center,
Amsterdam, The Netherlands
e-mail: L.Rammeloo@vumc.nl
A. M. van Furth :G. T. J. van Well
Department of Pediatric Infectious Diseases,
VU University Medical Center,
Amsterdam, The Netherlands
A. M. van Furth
e-mail: AM.vanFurth@vumc.nl
G. T. J. van Well
e-mail: G.vanWell@vumc.nl
Present address:
R. J. Bolt (*)
St. Franciscus Gasthuis,
P.O. Box 10900, Rotterdam 3004 BA,
The Netherlands
e-mail: r.bolt@sfg.nl
of tuberculosis [6]. Children in particular are at high risk of
the development of extra-pulmonary disease [5]. Clinical
manifestations of tuberculous pericarditis are nonspecific
and cardiopulmonary complaints usually develop later.
Accumulation of pericardial fluid may compromise venous
return, leading to cardiac failure.
Echocardiography plays a major role in confirming the
presence of a pericardial effusion. In addition, several
echocardiographic abnormalities including pericardial
thickening, exudative coating and strands crossing the
pericardial space are suggestive of tuberculous pericarditis.
Thickened pericardium and fibrin strands are highly
specific (94% and 88% respectively), and exudative coating
has a high sensitivity (100%) in tuberculous pericarditis [4].
The diagnosis is confirmed with detection of Mycobac-
terium tuberculosis in either pericardial fluid or pericardial
tissue. Pericardial fluid aspiration, however, has low
diagnostic yield, both for PCR and culture, whereas
pericardial biopsy provides the best chance of definitive
diagnosis [2, 6]. A positive tuberculin skin test may
increase the suspicion of tuberculous pericarditis, but a
negative skin test does not exclude the diagnosis. A
tuberculin skin test was not performed in this case because
the girl had been immunized with BCG. There was no
history of any family members being diagnosed with TBC.
The spread of tuberculosis to the pericardium, resulting
in an effusion, occurs most often from the mediastinal
lymph glands. However, pericarditis may also represent
reactivation of disease in the absence of an apparent
primary focus of infection [3].
Current recommendations for treatment of tuberculous
pericarditis include an initial four-drug regimen for a period
of 8 weeks with a subsequent continuation phase of treat-
ment for 4 months when the isolate is drug-susceptible [1].
Controversy exists with respect to the use of corticosteroids
for tuberculous pericarditis. The American Thoracic So-
ciety’s consensus statement on tuberculosis recommends
adjunctive therapy with corticosteroids (1 mg/kg of pred-
nisolone with tapering over 11 weeks) for tuberculous
pericarditis [1].
References
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Friedman LN, Fujiwara P, Grzemska M, Hopewell PC, Iseman
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Fig. 1 Echocardiography showing a large pericardial effusion with
exudative debris and fibrin strands. RV right ventricle, LV left
ventricle, LA left atrium, PE pericardial effusion
812 Eur J Pediatr (2008) 167:811–812


A 15-year-old girl with a large pericardial effusion

Bolt, R.J.

Rammeloo, L.A.J.

van Furth, A.M.

van Well, G.T.

NARCIS 

Roel J. Bolt

Lukas A. Rammeloo

A. Marceline van Furth

Gijs T. J van Well

American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis.

Comparison of PCR, culture, and histopathology for diagnosis of tuberculous pericarditis.

Extra-pulmonary tuberculosis in children.

Tuberculous pericardial effusion-mediastinal lymph glands: the cause and clue to the etiology.

Tuberculous pericarditis: optimal diagnosis and management.

Usefulness of echocardiographic intrapericardial abnormalities in the diagnosis of tuberculous pericardial effusion.

A 15-year-old girl with a large pericardial effusion

Abstract

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