"The heart has reasons
that reason does not
understand."
Jacques Benigne Bossuel
“Achy Breaky Heart”
Quiambao, Gisselle T., M.D.
June 17, 2010
Objectives


To discuss the protean extrapulmonary
manifestation of Tuberculosis
To discuss the management and approach to a
patient with pericardial effusion and
Tuberculous Pericarditis
General Profile




E.M.P
30 year old Male
Filipino
Engineer
History of Present Illness

7 months PTA
intermittent cough
(+) yellowish sputum
(-) dyspnea
(-) fever
(-) night sweats
(-) weight loss
History of Present Illness

Medical Consult done:
Chest X-Ray: Normal
Medication: Butamirate Citrate
Outcome: temporary relief of
cough but not resolved
History of Present Illness

6 months PTA
cough recurred
 (+) yellowish sputum
 (-) dyspnea
 (-) fever
 (-) night sweats
 (-) weight loss
History of Present Illness

Pulmonary consult:
AFB smear x 3 days: negative

He was treated as a case of Allergic cough
Medication: Desloratadine
Outcome: temporary relief of cough
History of Present Illness

5 months PTA
 (+)
cough recurred
yellowish sputum
 (-) fever
 (-) night sweats
 Pulmonary follow up
 Spirometry : mild obstructive ventilatory
defect
 Impression: Bronchial Asthma
History of Present Illness

4 months PTA
palpitations

intermittent, sudden, occurs during exertion and
even at rest
(-) cough
(-) dyspnea
(-) syncope
(-) chest pain
(-) fever
(-) heat or cold intolerance
(-) tremors
History of Present Illness

Cardiology consult:
12L ECG : Sinus tachycardia, left atrial
abnormality, non specific ST wave changes,
Incomplete RBBB
2D Echo : Mitral valve prolapse. LV
posterior wall hypertrophy
24 Hr Holter Monitoring: Rare episodes of
PACs and PVCs
History of Present Illness

2 months PTA
 (+)
Shortness of breath
Recurrence of
cough
yellowish sputum
 (+) 15 kg weight loss
 (-) fever
 Pulmonary follow up
 Impression: Allergic cough
History of Present Illness

1 month PTA
 Impression:
Pulmonary Consult
Bronchial Asthma
 Medications: Acetylcysteine
 Loratadine + Bethametasone
 Levofloxacin
 Salbutamol + guiafenesin +
bromhexedine
History of Present Illness

2 weeks PTA
 cardiomegaly,
Chest xray
clear lungs
 Impression: Upper Respiratory Tract
Infection
 Medication: Co-amoxiclav
Salbutamol expectorant
History of Present Illness

10 days PTA
patient developed
dyspnea
 (+) cough - yellowish sputum
Echo : Pericardial effusion
 Admitted and treated as a case of
CAP and Heart Failure
 2D
History of Present Illness

Few hours PTA
dyspnea persisted
 (+) cough - yellowish sputum
ADMISSION
Review of Systems:
(+) 15kg weight loss
(-) headache
(-) dizziness
(-) blurring of vision
(-) colds
(-) nape pains
(-) vomiting
(-) diarrhea
(-) polyphagia
(-) polydipsia
(-) polyuria
(-) dysuria
(-) myalgia
(-) athralgia
(-) abdominal pain
Past Medical History


(+) Allergic cough
(-) known PTB exposure
Family History




(+) Hypertension - Father
(+) Diabetes Mellitus - Mother
(-) Asthma
(-) Pulmonary Tuberculosis
Personal and Social History



Non smoker
Occasional alcoholic beverage drinker
No recent travel / exposure to TB
Physical Examination
GS: conscious, coherent, ambulatory,
oriented
 VS: BP 120/90 CR 73, RR 20 T 36.9C Wt.
115lbs
 HEENT: (+) subconjunctival hemorrhage
on the left eye, tonsils not enlarged, no
cervical lymphadenopathy, JVP 5
 Lungs: symmetrical chest wall expansion, no
lagging, no retractions, clear breath sounds
bilateral.

Physical Examination
Heart: Quiet precordium. No heaves, thrills
or lifts, regular rhythm, S1 and S2 were
soft, muffled, with 2/5 friction rub heard
at xiphoid process
 Abdomen: flabby, normoactive bowel
sounds, soft, non tender
 Extremities: no edema, no cyanosis, no
joint swelling, no active dermatoses.

Salient Features






Dyspnea
Cough >1 month
Weight loss
Hoarseness of voice
No fever
Previous finding of
pericardial effusion on
2dEcho




(+) Friction Rub
Clear lungs
AFB smear (-)
Chest X-ray
cardiomegaly
Admitting Impression:


Pericardial Effusion etiology to be determined
To consider Pulmonary Tuberculosis
On Admission




Chest X-Ray – normal, possible mild
cardiomegaly
12 Lead ECG
2d Echo
CBC
2dEcho
Ejection fraction of 59%.
 Thickened mitral leaflet and pulmonic
leaflets. Thickened cordae tendinae.
 Moderate to severe pericardial effusion.
 Color Flow Doppler study: Mitral,
Tricuspid and Pulmonic regurgitation mild.

Complete Blood Count
4/27/10
Hemoglobin
Hematocrit
15.4
45.3
WBC
Eosinophils
Segmenters
Lymphocytes
16.6
1.00
82.00
11.00
Monocytes
Platelet
6.00
303,000
Infection
Referral to Infectious Diseases
Pericardial Effusion
Referral to TCVS
nd
2






Hospital Day
Sputum AFB x 3 days
Sputum culture
ESR
UTZ of the upper abdomen
CT scan
Symptom: Hoarseness of Voice
t/c Pulmonary TB with TB Pericarditis
t/c Laryngeal TB
Medications:
HRZE quadtab 5 tabs/day (Day 12)
Prednisone 30 mg/tab, 1 tab 2x a day
Ultrasound of the upper
abdomen
 Minimal
ascites
 Gallbladder polyp
 Normal Liver, spleen and kidneys
 Incidental finding of bilateral pleural effusion




Sputum AFB – Negative for 3 days
Sputum culture - ESR – 16 mm/hr
CT scan – Pericardial effusion
PLAN:
Periardiostomy
 Flexible Nasopharyngolaryngoscopy

Normal larynx
5
1
6
2
3
7
6
4
1=vocal cords,
2=vestibular
fold,
3=epiglottis,
4=plica
aryepiglottica,
5=arytenoid
cartilage,
6=sinus
piriformis,
7=base of the
tongue
Nasopharyngolaryngoscopy
TB Laryngitis
Tuberculosis of the upper aerodigestive
tract is a rare entity.
 Incidence is less than 1% of all
tuberculosis cases.
 Pathogenesis is either primary or
secondary.

Primary: direct inoculation
 Secondary: haematogenous or lymphatic spread

TB Laryngitis

Clinical presentation:
 Dysphagia
 Hoarseness
 Chronic
cough.
 Posterior half of the larynx.
TB Laryngitis





Localization in the anterior half of the larynx
now occurs twice as often
Vocal cords (50-70%),
False cords (40-50%)
Epiglottis, aryepiglottic folds, arytenoids,
posterior commisure and/or subglottis (1015°%).
Laryngoscopic features mimic malignancy in
many cases.
LARYNGEAL TUBERCULOSIS CLINICALLY SIMILAR TO LARYNGEAL CANCER
S. K.Verma1, Sanjay Kumar
Lung India 2007; 24 : 87-89
TB Laryngitis




About 6% have no evidence of pulmonary
disease
30% show positive early morning urine culture
Biopsy of the primary growth itself is diagnostic
and may show caseating granulomatous
inflammation.
Microbiological confirmation, though desirable,
may not always be possible.
LARYNGEAL TUBERCULOSIS CLINICALLY SIMILAR TO LARYNGEAL CANCER
S. K.Verma1, Sanjay Kumar
Lung India 2007; 24 : 87-89
Management

The response to Anti-TB treatment is good.
LARYNGEAL TUBERCULOSIS CLINICALLY SIMILAR TO LARYNGEAL CANCER
S. K.Verma1, Sanjay Kumar
Lung India 2007; 24 : 87-89
Back to our patient…

Nasopharyngolaryngoscopy
Hoarseness secondary to Laryngeal TB
(Evidence of Reflux Disease Noted)
Nodular swelling of the right vocal fold

Treatment:
 Continue
HREZ treatment
 Fexofenadine 120mg/tab 1 tab daily at
bedtime
Back to our patient…


2d Echo: Pericardial effusion
CT scan of the chest
 Minimal pericardial effusion
Plan: Pericadiostomy
Potential algorithm for managing patients with a moderate to large pericardial effusion
Little, W. C. et al. Circulation 2006;113:1622-1632
Copyright ©2006 American Heart Association
Back to our patient…
 Pericardiostomy
 Problem:
with biopsy
Pericardiostomy not completed
due to thick and gritty pericardium.
 Pericardial biopsy
Pericardial Effusion
Histopath: Caseating granulomas
consistent with tuberculosis, pericardium
 Plan:

 Pericardiectomy
Normal Pericardium
Normal Myocardium
Pericardium 10x the
normal thickness
OR Findings

Multiple Casseating granulomas adhering to the
pericardium and myocardium.

Multiple hilar formations on the surface of the
heart

Histopath: Anterior pericardium 5/8/10:
Caseating granulomas consistent with
tuberculosis, pericardium
Summary









30 y/o male
Chronic cough
Dyspnea
Chest X-Ray – clear lungs, cardiomegaly
2dEcho – Pericardial Effusion
Sputum AFB Negative
+ Laryngeal TB
+ Tuberculosis – pericardium
+ Histopath findings of Tuberculosis
Final Diagnosis:




Disseminated Tuberculosis
TB Pericarditis with Pleural effusion
Laryngeal Tuberculosis
Anterior Pericardiectomy
Extrapulmonary Tuberculosis




Extrapulmonary tuberculosis occurs in any age
group
More in the 2nd and 3rd decades of life
Male preponderance.
Fever, anorexia, abdominal pain and cough are
more common in those with positive chest xrays.
Extrapulmonary Tuberculosis*
Emelita P. Ang, M.D.,Estelita M. Quimosing, M.D. and Bienvenido D. Alora, M.D
[Phil J Microbiol Infect Dis 1982; 11(2):115-123]
Extrapulmonary Tuberculosis




Proportion in all TB in USA :
7% (1963) to 18% (1987) to 20% (now)
Increase maybe due to HIV infection
More in minorities and foreign-borns
Lymphatic TB (30%) > Pleural TB (24%) >
Bone and joint TB (10%) > Genitourinary TB
(9%) > Miliary TB (8%) > Meningeal TB (6%)
(New York, 1995)
Extrapulmonary Tuberculosis

A negative chest x-ray does not exclude the
presence of extrapulmonary tuberculosis
because it can present as pleural effusion,
mediastinal mass, metastatic cancer, pneumonia,
pneumothorax, pulmonary neoplasm and
atelectasis.
Extrapulmonary Tuberculosis*
Emelita P. Ang, M.D.,Estelita M. Quimosing, M.D. and Bienvenido D. Alora, M.D
[Phil J Microbiol Infect Dis 1982; 11(2):115-123]
Pericardial Effusion


Patients presenting with a pericardial effusion
for the first time are usually hospitalized to
determine the cause of the effusion and to
observe for the development of cardiac
tamponade.
Disease-specific and adjunctive therapy is given
to those in whom pericarditis represents one
manifestation of systemic illness.
Management of Effusive and Constrictive Pericardial Heart Disease
Circulation Journal of American Heart Association 2002;105;2939-2942 Brian D. Hoit
Pericardial Effusion


In the absence of tamponade or suspected purulent
pericarditis, there are few indications for pericardial
drainage
Large effusions (when associated with pericarditis) that
are unresponsive to nonsteroidal anti inflammatory
drugs, corticosteroids, or colchicine, and unexplained
effusions, especially when tuberculosis is suspect or
when present for 3 months, warrant pericardiocentesis
Management of Effusive and Constrictive Pericardial Heart Disease
Circulation Journal of American Heart Association 2002;105;2939-2942 Brian D. Hoit
Tuberculous Pericarditis


Tuberculous pericarditis develops secondary to
contiguous spread from mediastinal nodes,
lungs, spine, or sternum, or during miliary
dissemination.
The onset may be abrupt or insidious with
symptoms such as chest pain, dyspnea, and
ankle edema.


First stage: diffuse fibrin deposition
Second stage: serosanguinous pericardial effusion then
develops.



Lymphocytes, monocytes and plasma cells replace the PMNs
Third stage: effusion absorbed and the pericardial
thickens
Fourth stage: pericardial space is obliterated by dense
adhesions and many granulomas are replaced by fibrous
tissues
Tuberculous Pericarditis


Cardiomegaly, tachycardia, fever, pericardial rub,
pulsus paradoxus, or distended neck veins may
be found on examination.
Pericardial biopsy yields a definitive diagnosis
more often than pericardial fluid alone.
Why was it missed?

The diagnosis of TB based solely on smear
microscopy—a method dating from the late
nineteenth century—is not sensitive. Many
patients with pulmonary TB and all patients with
exclusively extrapulmonary TB are missed by
smear microscopy.
Harrison’s Principles of Internal Medicine 7th ed
Accuracy of Sputum AFB Smear



It is the simplest, most rapid procedure to
detect the presence of acid-fast bacilli.
It will take 5,000 to 10,000 bacilli per ml of
sputum to detect their presence in smears.
Sensitivity is 22 to 43% in single smear, but
detection is improved by examining multiple
specimens.
Accuracy of AFB Smear Techniques at the Health Center LevelConcepcion F. Ang,
RMT, Myrna T. Mendoza, M.D. and Tessa Tan Torres, M.D.**(Phil J Microbiol Infect
Dis 1997; 26(4):153-155)


Bacterial pericarditis is treated with appropriate
systemic antibiotics, surgical exploration, and
drainage.
Pericardial effusion occasionally responds to the
addition of corticosteroids
Management of Effusive and Constrictive Pericardial Heart Disease
Circulation Journal of American Heart Association 2002;105;2939-2942 Brian D. Hoit
Management of Extrapulmonary TB



Treatment of pulmonary tuberculosis =
extrapulmonary tuberculosis.
Extrapulmonary: 6-month course of therapy
The addition of corticosteroids is recommended
for patients with tuberculous pericarditis and
tuberculous meningitis.
American Thoracic Society, CDC, and Infectious Diseases Society of America
MMWR: June 20, 2003 / Vol. 52 (RR11): 1-77
Management of Extrapulmonary TB

The risk of progression to constrictive
pericarditis or mortality is not altered by
corticosteroids. Open pericardial drainage is
favored over repeated pericardiocentesis.
Conclusion


Extrapulmonary involvement can occur in
isolation or along with a pulmonary focus
Extrapulmonary sites of infection
commonly include lymph nodes, pleura,
osteoarticular areas, cardiovascular, larynx
Conclusion

Not all patients with Extrapulmonary TB
will present with Pulmonary TB

Patients presenting with a pericardial
effusion for the first time are usually
hospitalized to determine the cause of the
effusion and to observe for the
development of cardiac tamponade.
Conclusion

Adjunctive corticosteroids may be beneficial
in patients with, tuberculous pericarditis, or
miliary tuberculosis along with standard
Anti-Tuberculosis agents
Thank you