Case Presentation: Tuberculosis (TB) remains a global health problem and extrapulmonary tuberculosis (EPTB) further adds to the developing countries’ fight against tuberculosis, with pericardial effusion being a potentially fatal complication. Here we report, a 19 year old male from South Asia with a past medical history of bilateral bronchiectasis (as shown in figure 1) and multiple episodes of pneumonia presented with fever, cough, and vomiting for 4 days. Vital signs showed pulse rate 96/min, blood pressure 70/40 mm Hg, O2 saturation 96% on room air and respiratory rate 24/min. Systemic examination revealed no significant findings. Electrocardiogram (EKG) showed sinus tachycardia with nonspecific ST and T changes. Bedside echocardiogram showed global hypokinesia with LVEF of 45%, moderate pericardial effusion and absent respiratory variation without any LV collapse, suggestive of early tamponade prompting emergency pericardiocentesis. The aspirated hemorrhagic pericardial fluid was analysed, revealing high levels of Lactate Dehydrogenase (LDH) (5000 U/L), polymorphonuclear leukocytosis and acid-fast bacilli leading to the diagnosis of pericardial tuberculosis. Adenosine Deaminase (ADA) level was 3 U/L. Antitubercular therapy (ATT) consisting of isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E) was administered for 2 months and HR for next 4 months. Serial echocardiograms during 6 month follow-ups showed an LVEF of 55% and decreased effusion. The patient had two episodes of pneumonia during the follow-up period, leading to consideration of immunodeficiency conditions. The results of flow cytometry are in table 1. The patient was diagnosed with Common Variable Immunodeficiency (CVID) and was started on intravenous immunoglobulin therapy every three weeks. At the 24 months follow up visit, the patient was asymptomatic.

Discussion: Due to the increasing TB burden in endemic areas, pericardial effusion should strongly raise suspicion of pericardial TB. Cardiac tamponade is due to fluid buildup within the pericardium which compresses the heart chambers leading to decreased venous return, ventricular filling and cardiac output [1]. Pericardial effusion, dilated IVC and hepatic veins, left ventricle with reduced end-diastolic and end-systolic dimensions are significant echocardiographic findings for cardiac tamponade [2,3]. Serum LDH levels can be used as a biochemical indicator of tuberculosis infection in resource limited areas [4,5]. The patient’s LDH level (5000 IU/L) was found to be high. Due to the stimulation of T-cell lymphocytes by mycobacterial antigens, measurement of ADA activity is a common diagnostic biomarker for EPTB [6] but in our case report ADA levels were below the diagnostic threshold. The optimal duration of treatment for EPTB is often debatable. Majority of data on the treatment of tuberculous pericarditis involves six months of ATT, consisting of HRZE for two months and HR continued for another four months [7]. In our case, the patient has CVID, making him susceptible to frequent infections, including EPTB. The shorter duration of ATT for 6 months proved to be effective in our immunocompromised patient.

Conclusions: We highlight the need for timely recognition of EPTB and the effectiveness of 6 months shorter duration ATT in treating pericardial TB even in the presence of immunocompromising conditions such as CVID.

IMAGE 1: Table 1: Results of flow cytometry

IMAGE 2: CT scan of the chest revealed varicose bronchiectasis with surrounding fibrosis and architectural distortion in the lateral segment of the right middle lobe and left lower lobe