Interventions for treating tuberculous pericarditis

Abstract

Background Tuberculous pericarditis can impair the heart's function and cause death; long term, it can cause the membrane to fibrose and constrict causing heart failure. In addition to antituberculous chemotherapy, treatments include corticosteroids, drainage, and surgery. Objectives To assess the effects of treatments for tuberculous pericarditis. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register (27 March 2017); the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library (2017, Issue 2); MEDLINE (1966 to 27 March 2017); Embase (1974 to 27 March 2017); and LILACS (1982 to 27 March 2017). In addition we searched the metaRegister of Controlled Trials (mRCT) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal using 'tuberculosis' and 'pericard*' as search terms on 27 March 2017. We searched ClinicalTrials.gov and contacted researchers in the field of tuberculous pericarditis. This is a new version of the original 2002 review. Selection criteria We included randomized controlled trials (RCTs) and quasi‐RCTs. Data collection and analysis Two review authors independently screened search outputs, evaluated study eligibility, assessed risk of bias, and extracted data; and we resolved any discrepancies by discussion and consensus. One trial assessed the effects of both corticosteroid and Mycobacterium indicus pranii treatment in a two‐by‐two factorial design ; we excluded data from the group that received both interventions. We conducted fixed‐effect meta‐analysis and assessed the certainty of the evidence using the GRADE approach. Main results Seven trials met the inclusion criteria; all were from sub‐Saharan Africa and included 1959 participants, with 1051/1959 (54%) HIV‐positive. All trials evaluated corticosteroids and one each evaluated colchicine, M. indicus pranii immunotherapy, and open surgical drainage. Four trials (1841 participants) were at low risk of bias, and three trials (118 participants) were at high risk of bias. In people who are not infected with HIV, corticosteroids may reduce deaths from all causes (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.59 to 1.09; 660 participants, 4 trials, low certainty evidence ) and the need for repeat pericardiocentesis (RR 0.85, 95% CI 0.70 to 1.04; 492 participants, 2 trials, low certainty evidence ). Corticosteroids probably reduce deaths from pericarditis (RR 0.39, 95% CI 0.19 to 0.80; 660 participants, 4 trials, moderate certainty evidence ). However, we do not know whether or not corticosteroids have an effect on constriction or cancer among HIV‐negative people ( very low certainty e...

Epidemiology of pericardial diseases in Africa: a systematic scoping review

“…The most important trial on the use of corticosteroid in tuberculous pericarditis, the IMPI trial, failed to show a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis or constrictive pericarditis 46. A recent Cochrane review on the interventions for treating tuberculous pericarditis suggested that in HIV-uninfected individuals, glucocorticoid probably reduce deaths from pericarditis (risk ratio (RR) 0.39, 95% CI 0.19 to 0.80), even though there was no significant effect on all-cause mortality (RR 0.80, 95% CI 0.59 to 1.09) and the need for repeat pericardiocentesis (RR 0.85, 95% CI 0.70 to 1.04) 47. In people infected with HIV, corticosteroids did not significantly reduce the occurrence of pericardial constriction (RR 0.55, 95% CI 0.26 to 1.16), the need for repeat pericardiocentesis (RR 1.02, 95% CI 0.89 to 1.18) and all-cause mortality 47.…”

“…A recent Cochrane review on the interventions for treating tuberculous pericarditis suggested that in HIV-uninfected individuals, glucocorticoid probably reduce deaths from pericarditis (risk ratio (RR) 0.39, 95% CI 0.19 to 0.80), even though there was no significant effect on all-cause mortality (RR 0.80, 95% CI 0.59 to 1.09) and the need for repeat pericardiocentesis (RR 0.85, 95% CI 0.70 to 1.04) 47. In people infected with HIV, corticosteroids did not significantly reduce the occurrence of pericardial constriction (RR 0.55, 95% CI 0.26 to 1.16), the need for repeat pericardiocentesis (RR 1.02, 95% CI 0.89 to 1.18) and all-cause mortality 47. It is worth mentioning that all the studies included in this review were conducted in Africa.…”

A case report of a child with probable drug resistant tuberculous pericarditis with a review of challenges involved in diagnosis, treatment and follow up of children with DR-TB pericarditis

“…Surgical drainage and pericardiectomy can been used where constriction or tamponade are detected. Open surgical drainage may be associated with less life-threatening re-accumulation requiring repeat pericardiocentesis in HIV negative patients [16]. Early pericardiectomy has been recommended to be of benefit to avert spread of inflammation to the myocardium and development of fibrosis and calcification of the pericardium [17].…”

“…Despite low certainty in the evidence, adjuvant corticosteroids are conditionally recommended by the World Health Organisation (WHO) for people being treated for tuberculous pericarditis [19]. A recent systematic review found some evidence that corticosteroids reduced mortality amongst HIV-negative patients but had little association with constriction [16]. Much of the available evidence includes high proportions of people living with HIV who were untreated with antiretroviral therapy making conclusions difficult to generalise.…”

Early operative outcome of pericardiectomy for symptomatic chronic tuberculous constrictive pericarditis

“…Once symptoms are present and imaging confirms chronic constriction then usually surgery is the only effective therapy 15 . Surgical pericardectomy is a complicated procedure with high morbidity and mortality reported in the literature.…”