ESC Guidelines for TB Pericarditis
The European Society of Cardiology recommends a 6-month antituberculosis regimen (rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months, followed by rifampicin and isoniazid for 4 months) combined with adjunctive prednisolone for 6 weeks to reduce constrictive pericarditis risk by 46%. 1, 2
Diagnostic Approach
Initial Non-Invasive Evaluation
- Obtain a chest radiograph to identify pulmonary TB, which is present in 30% of cases 1, 2
- Perform echocardiography to assess for pericardial effusion and thickening (>3 mm) 1, 2
- Consider CT or MRI of the chest looking for pericardial thickening and characteristic mediastinal/tracheobronchial lymphadenopathy (>10 mm with hypodense centers and matting), with sparing of hilar lymph nodes 1, 2
- Culture sputum, gastric aspirate, and urine for Mycobacterium tuberculosis in all patients 1, 2
- Do not rely on tuberculin skin testing as it is not helpful in adults regardless of TB prevalence 1
Pericardial Fluid Analysis (When Effusion Present)
The ESC defines two diagnostic categories 1:
"Definite" TB pericarditis:
- Tubercle bacilli demonstrated in pericardial fluid or pericardial tissue by culture or PCR (Xpert MTB/RIF) 1
"Probable" TB pericarditis:
- Proof of TB elsewhere in a patient with unexplained pericarditis PLUS lymphocytic pericardial exudate with elevated adenosine deaminase (ADA), unstimulated interferon-gamma (uIFN-γ), or lysozyme levels 1, 2
Diagnostic Test Performance
- Unstimulated interferon-gamma offers superior accuracy compared to ADA and Xpert MTB/RIF for microbiologically confirmed TB pericarditis 1, 2
- ADA ≥40 IU/L has 93% sensitivity and 97% specificity for TB pericarditis 2
- Very high ADA levels predict progression to constrictive pericarditis 2
- Xpert MTB/RIF is more specific (100% vs. 78%) but less sensitive (75% vs. 83%) than ADA 2
Risk Stratification in Endemic Areas
Calculate a pericardial score based on: fever (1 point), night sweats (1 point), weight loss (2 points), globulin levels, and peripheral WBC count 1, 2
- A score ≥6 is highly suggestive of TB pericarditis in endemic areas 2
Antituberculosis Treatment
Standard 4-drug regimen for 6 months total: 1, 2
- Intensive phase (2 months): Rifampicin + Isoniazid + Pyrazinamide + Ethambutol 1, 2
- Continuation phase (4 months): Rifampicin + Isoniazid 1, 2
Important caveat: Treatment for ≥9 months provides no better results and increases cost and poor compliance risk 1
Adjunctive Corticosteroid Therapy
Prednisolone for 6 weeks reduces constrictive pericarditis by 46% regardless of HIV status based on the IMPI trial 1, 2
Key Nuances About Steroids:
- Neutral effect on the combined outcome of death from all causes, cardiac tamponade requiring pericardiocentesis, or pericardial constriction 1, 2
- Increased risk of HIV-associated malignancies in HIV-positive patients receiving prednisolone 1, 2
- Despite this risk, the ESC still recommends adjunctive prednisolone given the significant reduction in constrictive pericarditis 1, 2
Additional Interventions to Prevent Constriction
- Intrapericardial urokinase may reduce the incidence of constriction 1, 2
- Appropriate antibiotic therapy is essential to prevent progression, as constrictive pericarditis still develops in 17-40% of cases despite rifampicin-based treatment (compared to 50% before effective chemotherapy) 1, 2
Clinical Presentations and Prognosis
TB pericarditis presents as 1:
- Pericardial effusion
- Effusive-constrictive pericarditis
- Constrictive pericarditis
- Chronic cardiac compression mimicking congestive heart failure (most common)
Mortality rate is 17-40% at 6 months after diagnosis 1
Constriction generally develops within 6 months of presentation with effusive pericarditis (effusive-constrictive pattern) 1
Critical Pitfalls
- The majority of data comes from endemic areas in underdeveloped countries and immunosuppressed patients; applicability to Western populations is questionable 1
- Tuberculous pericardial constriction is almost always associated with pericardial thickening 1
- Pericardiocentesis remains the gold standard for managing compressive pericardial fluid and its hemodynamic consequences 3