From the Guidelines
Tuberculous pericarditis is a form of extrapulmonary tuberculosis characterized by inflammation of the pericardium, requiring prompt initiation of anti-tubercular therapy.
Symptoms and Diagnosis
The symptoms of tuberculous pericarditis include fever, night sweats, weight loss, and pericardial effusion 1. Diagnosis is based on a combination of clinical presentation, imaging studies such as echocardiogram or CT scan, and laboratory tests including culture of sputum, gastric aspirate, and/or urine for Mycobacterium tuberculosis 1.
Treatment Options
The recommended treatment regimen consists of a 2-month intensive phase with isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by a 4-month continuation phase with isoniazid and rifampicin 1.
- First-line treatment: A 6-month regimen is adequate for patients with pericardial tuberculosis 1.
- Adjunctive corticosteroid therapy: May be considered to reduce inflammation and prevent constrictive pericarditis, but its use is not routinely recommended due to limited evidence of benefit 1. Some patients may benefit from selective use of corticosteroids, such as those with large pericardial effusions or early signs of constriction 1.
Key Considerations
- Pericardiocentesis may be necessary for diagnostic or therapeutic purposes, especially in cases of cardiac tamponade 1.
- Pericardial biopsy may be considered in areas where tuberculosis is not endemic or when empiric antituberculosis treatment is not effective 1.
From the FDA Drug Label
Surgery may be necessary to obtain specimens for diagnosis and to treat such processes as constrictive pericarditis and spinal cord compression from Pott’s Disease Corticosteroids have been shown to be of benefit in preventing cardiac constriction from tuberculous pericarditis and in decreasing the neurologic sequelae of all stages of tuberculosis meningitis, especially when administered early in the course of the disease. Miscellaneous: ...tuberculosis with pleural or pericardial effusion (appropriate antituberculous chemotherapy must be used concurrently when treating any tuberculosis complications);
The symptoms of Tuberculosis (TB) pericarditis are not explicitly stated in the provided drug labels. Treatment options for TB pericarditis include:
- Surgery to treat constrictive pericarditis
- Corticosteroids, such as prednisolone, to prevent cardiac constriction
- Antituberculous chemotherapy, which must be used concurrently with corticosteroids 2 3
From the Research
Symptoms of Tuberculosis (TB) Pericarditis
- The symptoms of TB pericarditis can vary, but common manifestations include:
- Cardiac tamponade as the initial manifestation of tuberculosis 4
- Purulent pericarditis, characterized by gross pus in the pericardium or microscopically purulent effusion 5
- Silent (often large) relapsing pericardial effusion 5
- Effusive-constrictive pericarditis 5
- Toxic symptoms with persistent fever 5
- Acute, subacute, or chronic constriction 5
- TB pericarditis can also present with non-specific symptoms such as fever, chest pain, and shortness of breath
Treatment Options for TB Pericarditis
- The treatment of TB pericarditis typically consists of:
- A 4-drug regimen (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months, followed by 2 drugs (isoniazid and rifampicin) for 4 months, regardless of HIV status 6
- Adjunctive corticosteroids may be used, but their effectiveness in reducing mortality or pericardial constriction is uncertain, and their safety in HIV-infected patients has not been established conclusively 6
- Surgical resection of the pericardium may be indicated for patients with calcific constrictive pericarditis or persistent signs of constriction after a 6-8 week trial of antituberculosis treatment in patients with noncalcific constrictive pericarditis 6
- Pericardiocentesis remains the gold standard for managing compressive pericardial fluid and its adverse hemodynamic sequelae 7
- A combined two-test approach, starting with Xpert MTB/RIF, followed by either adenosine deaminase (ADA) or interferon gamma (IFN-γ), may provide enhanced specificity and sensitivity for diagnosis 7
Complications and Prevention
- Constrictive pericarditis is a major long-term complication of TB pericarditis, and is a significant cause of heart failure in Sub-Saharan Africa 7
- Recent studies have revealed a strong profibrotic transcriptomic profile in pericardial fluid, with high amounts of pro-inflammatory cytokines and low levels of anti-fibrotic tetrapeptide N-Acetyl-Seryl-Aspartyl-Lysyl-Proline (Ac-SDKP) 7
- The value of effective pericardiocentesis in reducing pro-inflammatory and pro-fibrotic cytokines and peptides to prevent pericardial constriction has yet to be established, but has generated hypotheses for ongoing and future research 7