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      Tuberculosis Pericarditis with Cardiac Tamponade: Management in the Resource-Limited Setting

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          Abstract

          We report a case of human immunodeficiency virus–associated pericardial tuberculosis complicated by cardiac tamponade. Emergency management and subsequent therapeutic interventions are described and then discussed with particular focus on resource-limited settings. The paucity of evidence to support clinical decisions is emphasized and the need for well designed diagnostic and therapeutic studies is highlighted.

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          Treatment of active tuberculosis in HIV-coinfected patients: a systematic review and meta-analysis.

          Waliul Khan, Madhukar Pai, Dick Menzies … (2010)
          Patients with human immunodeficiency virus (HIV) infection and tuberculosis have an increased risk of death, treatment failure, and relapse. A systematic review and meta-analysis of randomized, controlled trials and cohort studies was conducted to evaluate the impact of duration and dosing schedule of rifamycin and use of antiretroviral therapy in the treatment of active tuberculosis in HIV-positive patients. In included studies, the initial tuberculosis diagnosis, failure, and/or relapse were microbiologically confirmed, and patients received standardized rifampin- or rifabutin-containing regimens. Pooled cumulative incidence of treatment failure, death during treatment, and relapse were calculated using random-effects models. Multivariable meta-regression was performed using negative binomial regression. After screening 5158 citations, 6 randomized trials and 21 cohort studies were included. Relapse was more common with regimens using 2 months rifamycin (adjusted risk ratio, 3.6; 95% confidence interval, 1.1-11.7) than with regimens using rifamycin for at least 8 months. Compared with daily therapy in the initial phase (n=3352 patients from 35 study arms), thrice-weekly therapy (n=211 patients from 5 study arms) was associated with higher rates of failure (adjusted risk ratio, 4.0; 95% confidence interval, 1.5-10.4) and relapse [adjusted risk ratio, 4.8; 95% confidence interval, 1.8-12.8). There were trends toward higher relapse rates if rifamycins were used for only 6 months, compared with > or =8 months, or if antiretroviral therapy was not used. This review raises serious concerns regarding current recommendations for treatment of HIV-tuberculosis coinfection. The data suggest that at least 8 months duration of rifamycin therapy, initial daily dosing, and concurrent antiretroviral therapy might be associated with better outcomes, but adequately powered randomized trials are urgently needed to confirm this.
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            Diagnosing tuberculous pericarditis.

            A F Doubell, H Reuter, Jefferey L. Burgess … (2006)
            Definitive diagnosis of tuberculous pericarditis requires isolation of the tubercle bacillus from pericardial fluid, but isolating the organism is often difficult. To improve diagnostic efficiency for tuberculous pericarditis, using available tests. Prospective observational study. Consecutive patients (n = 233) presenting with pericardial effusions underwent a predetermined diagnostic work-up. This included (i) clinical examination; (ii) pericardial fluid tests: biochemistry, microbiology, cytology, differential white blood cell (WBC) count, gamma interferon (IFN-gamma), adenosine deaminase (ADA) levels, polymerase chain reaction testing for Mycobacterium tuberculosis; (iii) HIV; (iv) sputum smear and culture; (v) blood biochemistry; and (vi) differential WBC count. A model was developed using 'classification and regression tree' analysis. The cut-off for the total diagnostic index (DI) was optimized using receiver operating characteristic (ROC) curves. Fever, night sweats, weight loss, serum globulin (>40 g/l) and peripheral blood leukocyte count ( or=50 pg/ml, concentration had 92% sensitivity, 100% specificity and a positive predictive value (PPV) of 100% for the diagnosis of tuberculous pericarditis; pericardial fluid ADA >or=40 U/l had 87% sensitivity and 89% specificity. A diagnostic model including pericardial ADA, lymphocyte/neutrophil ratio, peripheral leukocyte count and HIV status had 96% sensitivity and 97% specificity; substituting pericardial IFN-gamma for ADA yielded 98% sensitivity and 100% specificity. Basic clinical and laboratory features can aid the diagnosis of tuberculous pericarditis. If available, pericardial IFN-gamma is the most useful diagnostic test. Otherwise we propose a prediction model that incorporates pericardial ADA and differential WBC counts.
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              Mortality in patients treated for tuberculous pericarditis in sub-Saharan Africa.

              Frans Maritz, Damon A. Parrish, K Ngu Blackett … (2007)
              To determine the mortality rate and its predictors in patients with a presumptive diagnosis of tuberculous pericarditis in sub-Saharan Africa. Between 1 March 2004 and 31 October 2004, we enrolled 185 consecutive patients with presumed tuberculous pericarditis from 15 referral hospitals in Cameroon, Nigeria and South Africa, and observed them during the 6-month course of antituberculosis treatment for the major outcome of mortality. This was an observational study, with the diagnosis and management of each patient left at the discretion of the attending physician. Using Cox regression, we have assessed the effect of clinical and therapeutic characteristics (recorded at baseline) on mortality during follow-up. We obtained the vital status of 174 (94%) patients (median age 33; range 14 - 87 years). The overall mortality rate was 26%. Mortality was higher in patients who had clinical features of HIV infection than in those who did not (40% v. 17%, p=0.001). Independent predictors of death during followup were: (i) a proven non-tuberculosis final diagnosis (hazard ratio (HR) 5.35, 95% confidence interval (CI) 1.76 - 16.25), (ii) the presence of clinical signs of HIV infection (HR 2.28, CI 1.14 - 4.56), (iii) coexistent pulmonary tuberculosis (HR 2.33, CI 1.20 - 4.54), and (iv) older age (HR 1.02, CI 1.01 - 1.05). There was also a trend towards an increase in death rate in patients with haemodynamic instability (HR 1.80, CI 0.90 - 3.58) and a decrease in those who underwent pericardiocentesis (HR 0.34, CI 0.10 - 1.19). A presumptive diagnosis of tuberculous pericarditis is associated with a high mortality in sub-Saharan Africa. Attention to rapid aetiological diagnosis of pericardial effusion and treatment of concomitant HIV infection may reduce the high mortality associated with the disease.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Am J Trop Med Hyg
                Journal ID (publisher-id): tpmd
                Title: The American Journal of Tropical Medicine and Hygiene
                Publisher: The American Society of Tropical Medicine and Hygiene
                ISSN (Print): 0002-9637
                ISSN (Electronic): 1476-1645
                Publication date (Print): 06 December 2010
                Publication date PMC-release: 06 December 2010
                Volume: 83
                Issue: 6
                Pages: 1311-1314
                Affiliations
                Hlabisa Hospital, Hlabisa, KwaZulu-Natal, South Africa; Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, KwaZulu-Natal, South Africa; Division of Infectious and Tropical Diseases, University of Pavia, San Matteo Hospital Foundation, Pavia, Italy
                Author notes
                *Address correspondence to Richard J. Lessells, Africa Centre for Health and Population Studies, University of KwaZulu-Natal, PO Box 198, Mtubatuba, KwaZulu-Natal 3935, South Africa. E-mail: rlessells@ 123456africacentre.ac.za
                Article
                DOI: 10.4269/ajtmh.2010.10-0271
                PMC ID: 2990051
                PubMed ID: 21118941
                SO-VID: fb69aa30-1ba9-4c37-88a6-231c0ea720e6
                Copyright © ©The American Society of Tropical Medicine and Hygiene
                License:

                This is an Open Access article distributed under the terms of the American Society of Tropical Medicine and Hygiene's Re-use License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 May 2010
                Date accepted : 16 June 2010
                Categories
                Subject: Articles
                Series title: Case Report

                ScienceOpen disciplines: Infectious disease & Microbiology
                Data availability:
                ScienceOpen disciplines: Infectious disease & Microbiology

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