The case of a 59 year male with acute tuberculous pericardial abscess who presented with cough, dyspnoea, haemoptysis, signs of Tamponade and a large Pleural Effusion is reported. Performing Pericardiocentesis did not improve his symptoms hence he was subjected to surgery. Acute tuberculous pericardial abscess was the diagnosis made after histopathology which was successfully managed with sternotomy along with drainage of pus

Faheem-ul-Haq,

Fatimi, Saulat H.

Hanif, Hashim Muhammad

Jalil, Fatima

Muzaffar, Marium

eCommons@AKU

eCommons@AKUSection of Cardiothoracic Surgery Department of SurgeryMarch 2011Tuberculous pericardial abscess with impendingpericardial effusion and cardiac tamponadeSaulat H. FatimiAga Khan UniversityFaheem-ul-HaqAga Khan UniversityFatima JalilAga Khan UniversityMarium MuzaffarAga Khan UniversityHashim Muhammad HanifAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracicPart of the Surgery CommonsRecommended CitationFatimi, S., Faheem-ul-Haq, ., Jalil, F., Muzaffar, M., Hanif, H. (2011). Tuberculous pericardial abscess with impending pericardialeffusion and cardiac tamponade. Journal of the Pakistan Medical Association, 61(3), 286-7.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracic/13AbstractThe case of a 59 year male with acute tuberculouspericardial abscess who presented with cough, dyspnoea,haemoptysis, signs of Tamponade and a large PleuralEffusion is reported. Performing Pericardiocentesis did notimprove his symptoms hence he was subjected to surgery.Acute tuberculous pericardial abscess was the diagnosismade after histopathology which was successfully managedwith sternotomy along with drainage of pus.Keywords: Tuberculous pericardial abscess, Cardiactamponade.IntroductionTuberculosis is a common cause of pericardial effusionespecially in the developing countries. Despite the decline inmortality due to tuberculosis and an overall decrease in theincidence, tuberculosis and its complications remain a serioushealth problem. However, tuberculous pericardial effusionleading to pericardial abscess is a rare presentation. Largepericardial effusions are uncommon and their manifestation ascardiac tamponade is rare.1 It is known that the most commoncause of pericardial effusion is malignancy followed bytuberculosis. Previously it was known that the most efficientand safe way to treat pericardial effusion waspericardiocentesis.2 We however, have reported an unusualcase of tuberculous pericardial effusion which was notalleviated with the former but was successfully treated withsternotomy, thus proving it an effective way of treatment.Case PresentationA 59-year-old male with no known co-morbidspresented in the Emergency Room with a 2-day history offever and cough. General physical and systemicexamination was unremarkable and he was vitally stable.Chest x-ray was normal. Four days later he returned with epersisting fever, cough, dyspnoea and haemoptysis. Clinicalexamination revealed displaced apex beat, increasedAnterior Posterior (AP) diameter (bilateral harsh vesicularbreathing), reduced air entry, dull to percussion and tenderright hypochondrium / epigastrium. Echocardiogramshowed reduced left ventricular function with a mildcircumferential pericardial effusion. Moreover, signs oftamponade, right atrial collapse with significant variationand large Pericardial Effusion - 52 mm were seen.His symptoms amplified to worsening of dyspnoea,rise in jugular venous pressure and left ventriculardystrophy with occult magnetic resonance.Pericardiocentesis was attempted in cardiac care unit, withevacuation of 1500cc of blood. During pericardiocentesis,the patient became severely hypotensive and arrested. Afterperforming CPR for 2 minutes, he was successfullyresuscitated. However, due to his serious condition, he wastaken to the Operation Room (OR) for median sternotomy.The patient was intubated prior to taking him to the OR. A standard median sternotomy was performed. Asthe chest was opened, pericardium was found bulging andthick in nature. Approximately 1 Liter of pus was evacuated.The pericardium from the anterior portion of heart i.e. fromthe right ventricle and right atrium was completely resectedand sent for cultures for tuberculosis, bacterial, fungalgrowth and histopathology. The previously placedpericardiocentesis catheter was found going into the rightventricle from the inferior side and the chest was closedwith 4 chest tubes in place. Post operatively, the patient'srecovery remained uneventful. He was discharged after four days with clean woundand stable condition. Acid fast bacilli (AFB) cultureconcluded Mycobacterium tuberculosis. Gross and micro-medium biopsy exhibited dense acute and chronicinflammation with evidence of abscess formation. Hence, adiagnosis of 'Acute pyogenic non - specific inflammation ofpericardial tissue and pericardial fat with abscess formationand granulation tissue' was made. DiscussionTuberculosis is a disease that plagues much of thedeveloping and underdeveloped world, including Pakistan.It is estimated to occur in 1% to 2% of cases of pulmonarytuberculosis. A subtype, tuberculous pericarditis usuallypresents as an insidious progressive chronic disease whichcan lead to haemodynamic disturbances. Previous studies show that tuberculosis isresponsible for around 4% of cases of acute pericarditis, 7%cases of cardiac tamponade, and, approximately 6% of286 J Pak Med AssocCase ReportTuberculous pericardial abscess with Impending PericardialEffusion and Cardiac TamponadeSaulat Hasnain Fatimi,1 Faheem-ul-Haq,2 Fatima Jalil,3 Marium Muzaffar,4 Hashim Muhammad Hanif5Department of Surgery, Division of Cardiothoracic Surgery,1-3 Medical College,4,5 Aga Khan University, Karachi, Pakistan.occurrences of constrictive pericarditis in the industrializedworld.1 However, in developing countries, where most ofthe world's population live, tuberculosis is responsible forapproximately 70% cases of large pericardial effusion andfor a good number of constrictive pericarditis cases. Beinga hazardous disease tuberculous pericarditis has a mortalityof 17% to 40%; constriction occurs in a comparablepercentage of cases after tuberculous pericardial effusion.9Despite sufficient remedy, a subset of patients maysooner or later entail to pericardiectomy. Incompletepericardial resections are also coupled with an amplifiedincidence of late complications.2 Therefore, early diagnosisand establishment of appropriate therapy are vital to avertmortality. A definite or verified diagnosis depends ondemonstration of tubercle bacilli in pericardial fluid or onhistologic section of the pericardium. A probable orpresumed diagnosis is based on proof of tuberculosiselsewhere in a patient with otherwise inexplicablepericarditis, a lymphocytic pericardial exudate withelevated biomarkers of tuberculous infection, and/orappropriate response to a trial of antituberculosischemotherapy.9This particular case in reference is a classic instanceof how a subtype of this condition changed into a life-threatening condition. A large abscess developed in justabout a week, without any past history and a previouslynormal chest X-ray and AFB culture. An Indian case study reflects on similarcircumstances. It elucidated the fact that the retrogradespread from mediastinal or hilar lymph nodes may beresponsible for extra pulmonary TB. It is further clarifiedthat even with anti-TB treatment, 30% to 50% of patientswill progress to effusive or constrictive pericarditis,myocarditis or tamponade.6Echocardiogram was done on our patient as it haspreviously been considered as a pertinent tool. A study donein Pakistan at Aga Khan University Hospital (AKUH)shows that Transthoracic echocardiography is the goldstandard for rapid and confirmatory diagnosis of pericardialeffusion and cardiac tamponade.5 Other studies have shownefficacy of Computed Tomography and MagneticResonance Imaging as well.3 For this particular case, theoperative procedure planned was sternotomy along withdrainage of pus which proved successful and the patientrecovered without any complications. Surgical resection ofthe pericardium is indicated for cases with calcificconstrictive pericarditis or with persistent signs ofconstriction after a 6 to 8 week trial of antituberculosistreatment in patients with noncalcific constrictivepericarditis.9 Further indications include recurrent or life-threatening tamponade, or when there is persistent elevationof systemic venous pressure unrelieved bypericardiocentesis which was the situation pertaining to thecase reported.1 Other studies have however shownadditional methods such as video-assisted thoracoscopicpericardial fenestration (VATSPF) which was performed forthe diagnosis and treatment in one instance.7 VATSPF wasfound to be useful procedure not only for diagnosis but alsofor release of tuberculous pericarditis with cardiactamponade and for prophylaxis of constrictive pericarditis.8ConclusionsDespite the decline in mortality due to tuberculosisand an overall decrease in the annual new case rate,tuberculosis remains a serious health problem. Thuscomplications like pericarditis, tamponade and abscess areimminent and despite adequate drug therapy, one third toone half of the patients eventually require Pericardiectomy.Hence we conclude that pericardial abscess with pericardialeffusion is an uncommon complication of tuberculouspericarditis, which should be considered while treatingpatients of PE, and recommended surgical option is mediansternotomy with drainage of pericardial abscess.References1. Flower NO. Tuberculous pericarditis. JAMA 1991, 266: 99-103.2. Gregory AK, Connery CP, Anagnostopoulos CE. A late complication oftuberculous pericarditis after partial pericardial resection. Ann Thorac Surg1998; 65: 542-4. 3. Gulati Gs, Sharma S. Pericardial abscess occurring after tuberculouspericarditis: image morphology on computed tomography and magneticresonance imaging. Clin Radiol 2004; 59: 514-9. 4. Gladych E, Goland S, Attali M, Somin M, Malnick SD. Cardiac tamponade asa manifestation of tuberculosis. South Med J 2001; 94: 525-8.5. Quraishi AR, Khan AA, Kazmi KA, Najaf SM, Basir MN, Shafqat A, etal. Clinical and echocardiographic characteristics of patients withsignificant pericardial effusion requiring pericardiocentesis. J Pak MedAss 2005; 55: 66-70.6. Cherian G, Habashy AG, Uthaman B, Hanna RM. Tuberculous pericardialeffusion - mediastinal lymph glands: the cause and clue to the etiology. IndianHeart J 2003; 55: 228-33.7. Kameyama K, Huanq CL, Okamoto T, Ishikawa S, Yamamoto Y, Yokomise H.Video-assisted thoracoscopic pericardial fenestration for tuberculouspericardial effusion. Jpn J Thorac Cardiovasc Surg 2004; 52: 68.8. Kameyama K, Huanq CL, Okamoto T, Ishikawa S, Yamamoto Y, Yokomise H.Video-assisted thoracoscopic pericardial fenestration for tuberculouspericardial effusion. Jpn J Thorac Cardiovasc Surg 2004; 52: 68-70. 9. Syed FF, Mayosi BM. A modern approach to tuberculous pericarditis. ProgCardiovasc Dis 2007; 50: 218-36.Vol. 61, No. 3, March 2011 287

Tuberculous pericardial abscess with impending pericardial effusion and cardiac tamponade

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Tuberculous pericardial abscess with impending pericardial effusion and cardiac tamponade

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