A 20 year old woman originally from Ethiopia presented to a Chicago hospital with complaints of one month of left sided pleuritic chest pain and two weeks of cough and shortness of breath. Physical examination was remarkable for tachypnea and distant heart sounds. A chest radiograph showed cardiomegaly. Computerized tomography (CT) of the chest revealed a large pericardial effusion with bilateral mediastinal lymphadenopathy. Transthoracic echocardiogram showed constrictive physiology with impending tamponade. The patient was started on intravenous fluids to keep right ventricular pressures greater than the pericardial pressures. Pericardiocentesis yielded 300 milliliters of hemorrhagic fluid. Gram stain and acid‐fast bacilli (AFB) stains were negative. Sputum cultures were positive forMycobacterium tuberculosis. A pre‐tracheal lymph node pathology showed necrotizing granulomatous inflammation.. Pericardial tissue biopsy was not positive for AFB stains. The patient was discharged home on a tapering regimen of oral corticosteroids and 4 drug antituberculosis regimen.
Tuberculosis is responsible for approximately 70% of cases of large pericardial effusion and most cases of constrictive pericarditis in developing countries, compared to only 4% in industrialized nations. Tuberculous pericardial effusion usually develops insidiously, presenting with nonspecific constitutional symptoms such as fever, night sweats, fatigue, and weight loss. Other symptoms may include chest pain, cough, and dyspnea. Cardiac tamponade is present in 10% of patients with tuberculous pericardial effusion, and pericardial fluid is hemorrhagic in 80% of cases. A definitive diagnosis can be made by demonstration of tubercle bacilli in pericardial fluid or on histopathology of the pericardium. A probable diagnosis is based on evidence of TB elsewhere in a patient with otherwise unexplained pericarditis or a lymphocytic pericardial exudate with elevated adenosine deaminase levels, and/or appropriate response to a trial of antituberculosis therapy. Treatment typically consists of a rifampin, isoniazid, pyrazinamide, and ethambutol for at least 2 months, followed by isoniazid and rifampin (total of 6 months of therapy). The effectiveness of adjunctive corticosteroid therapy is uncertain. Surgical resection is indicated for calcific constrictive pericarditis or persistent signs of constriction after 6‐8 weeks medical therapy.
Although uncommon, tuberculous pericardial effusion is important to consider in the United States, especially in light of increasing immigration trends. Prompt diagnosis is critical because if left untreated, mortality can be as high as 40%.