Tuberculous pericarditis summary


 * Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

==Approach to patients with suspected tuberculous pericarditis ==
 * 1) Initial evaluation
 * 2) *Chest radiograph may reveal changes suggestive of pulmonary tuberculosis in 30% of cases.
 * 3) *Echocardiogram: the presence of a large pericardial effusion with frond-like projections, and thick "porridge-like" exudate is suggestive of an exudate but not specific for a tuberculous etiology.
 * 4) *CT scan and/or MRI of the chest are alternative imaging modalities where available: for evidence of pericardial effusion and thickening (>5 mm) and typical mediastinal and tracheobronchial lymphadenopathy (>10 mm, hypodense centers, matting), with sparing of hilar lymph nodes.
 * 5) *Culture of sputum, gastric aspirate, and/or urine should be considered in all patients.
 * 6) *Right scalene lymph node biopsy if pericardial fluid is not accessible and lymphadenopathy is present.
 * 7) *Tuberculin skin test is not helpful regardless of the background prevalence of tuberculosis.5,50
 * 8) Pericardiocentesis
 * 9) *Therapeutic pericardiocentesis is indicated in the presence of cardiac tamponade.
 * 10) *Diagnostic pericardiocentesis should be considered in all patients with suspected tuberculous pericarditis, and the following tests should be performed:
 * 11) *#Direct inoculation of the pericardial fluid into double-strength liquid Kirchner culture medium at the bedside and culture for M tuberculosis.
 * 12) *#Biochemical tests to distinguish between an exudate and a transudate (fluid and serum protein; fluid and serum LDH).
 * 13) *#Indirect tests for tuberculous infection: ADA, IFN-, or lysozyme assay.
 * 14) Pericardial biopsy
 * 15) *"Therapeutic" biopsy: as part of surgical drainage in patients with severe tamponade relapsing after pericardiocentesis.
 * 16) *Diagnostic biopsy: in areas in which TB is endemic, a diagnostic biopsy is not required before commencing empirical antituberculosis treatment. In areas in which TB is not endemic, a diagnostic biopsy is recommended in patients with >3 weeks of illness and without etiologic diagnosis having been reached by other tests.3
 * 17) Empirical antituberculosis chemotherapy
 * 18) *Tuberculosis endemic in the population: trial of empirical antituberculous chemotherapy is recommended for exudative pericardial effusion, after other causes such as malignancy, uremia, and trauma have been excluded.
 * 19) *Tuberculosis not endemic in the population: when systematic investigation fails to yield a diagnosis of tuberculous pericarditis, there is no justification for starting antituberculosis treatment empirically.