Diagnosis and Management of Tuberculous Pericarditis: What Is New?

Abstract

Purpose of Review This review provides an update on the immunopathogenesis of tuberculous pericarditis (TBP), investigations to confirm tuberculous etiology, the limitations of anti-tuberculous therapy (ATT), and recent efficacy trials. Recent Findings A profibrotic immune response characterizes TBP, with low levels of AcSDKP, high levels of γ-interferon and IL-10 in the pericardium, and high levels of TGF-β and IL-10 in the blood. These findings may have implications for future therapeutic targets. Despite advances in nucleic acid amplification approaches, these tests remain disappointing for TBP. Trials of corticosteroids and colchicine have had mixed results, with no impact on mortality, evidence of a reduction in rates of constrictive pericarditis and potential harm in those with advanced HIV. Small studies suggest that ATT penetrates the pericardium poorly. Given that there is a close association between high bacillary burden and mortality, a rethink about the optimal drug doses and duration may be required. Summary The high mortality and morbidity from TBP despite use of anti-tuberculous drugs call for researches targeting hostdirected immunological determinants of treatment outcome. There is also a need for the identification of steps in clinical management where interventions are needed to improve outcomes. Keywords Tuberculous pericarditis . Mycobacterium tuberculosis Case VignetteA 33-year-old woman, HIV positive with a CD4 count of 21 cells/μL, presented with weight loss, night sweats, and shortness of breath. At presentation, recorded examination findings were temperature of 35.5°C, peripheral oxygen saturation 100%, respiratory rate 22/min, heart rate 112 beats/ min, blood pressure 106/62 mmHg with a pulsus paradoxus of 16 mmHg, and distant heart sounds. Her admission electrocardiogram (ECG), chest radiograph (CXR), and point of This article is part of the Topical Collection on Pericardial Disease

Diagnostic values of Xpert MTB/RIF, T-SPOT.TB and adenosine deaminase for HIV-negative tuberculous pericarditis in a high burden setting: a prospective observational study

“…According to the DOC curve, 48.5 SFCs per million PEMC was the optimal cut-off value of T-SPOT.TB, which showed the best diagnostic accuracy among the single diagnostic tests (DOR = 183.8); (3) the two clinical cut-off points (30 U/L and 40 U/L) of ADA showed no statistically significant difference in diagnosing TBP, and 41.5 U/L was the optimal cut-off value; (4) The two-step algorithm using Xpert followed by T-SPOT.TB (≥ 48.5 SFCs/10 6 PEMC [cut-off value]) showed excellent diagnostic accuracy (DOR = 252.0) with a sensitivity and specificity of 92.3% and 95.5%, respectively. www.nature.com/scientificreports/ For TBP patients, the presence of HIV infection contributed to the complexity of the disease process considerably 25 . The proportion of microbiologically confirmed TBP patients in HIV-negative cohorts was higher than that in HIV-positive cohorts 26 , and the positive histopathological results of pericardial tissue, such as granuloma, were poor in HIV-positive patients 27 .…”

“…For TBP patients, the presence of HIV infection contributed to the complexity of the disease process considerably 25 . The proportion of microbiologically confirmed TBP patients in HIV-negative cohorts was higher than that in HIV-positive cohorts 26 , and the positive histopathological results of pericardial tissue, such as granuloma, were poor in HIV-positive patients 27 .…”

The Optimal Duration of Anti-Tuberculous Therapy Before Pericardiectomy in Constrictive Tuberculous Pericarditis

“…The current standard anti-tuberculous regimen of rst-line drugs (isoniazid, rifampin, pyrazinamide, and ethambutol) achieves satisfactory cure rate in pulmonary tuberculosis [17] , but its effect on the constrictive tuberculous pericarditis has been unclear. There have been several studies indicating that the concentration of anti-tuberculous drugs is low in the pericardial space because of poor penetration, especially rifampin and pyrazinamide [18][19][20] . Due to the inadequate concentration of primary sterilizing effect drugs, the effect of anti-tuberculous treatment on the development of constrictive pericarditis is limited [8] , which suggests that constrictive tuberculous pericarditis is chronic and progressive in most cases.…”

Constrictive Pericarditis and Tuberculosis: Is It Worth More Attention？

“…Neither a relatively inexpensive, rapid, accurate, and widely available test has been developed, nor the determinants and drivers of TBCP have been understood, much less is the pharmacokinetics and pharmacodynamics of anti-tuberculous drugs in both plasma and the pericardium and their impact on short-and long-term outcomes. Therefore, there seems to be a long way to go [73] . This is the mind mapping of this review, and the review will introduce one by one according to the part of the mind mapping.…”