Case 13351

Tuberculous Pericarditis
Published on 15.03.2016

DOI: 10.1594/EURORAD/CASE.13351
ISSN: 1563-4086
Section: Chest imaging
Area of Interest: Thorax
Procedure: Education
Imaging Technique: Conventional radiography
Imaging Technique: CT
Imaging Technique: MR
Special Focus: Infection Case Type: Clinical Cases
Authors: Marques, Inês; Melo, Pedro; Castelo, Diogo;
Florim, Sofia; Matos, Elizabeth; Branco, Inês; Portugal,
Pedro
Patient: 28 years, male

Clinical History:

A previously healthy 28 year-old male, from Guinea Bissau, who had lived in Europe for 4 years, presented to the
emergency department with fever, dry cough, dyspnoea and weight loss (15kg in 3 months). Physical examination
revealed fever (38.2ºC) and reduced respiratory sounds in the left hemithorax. HIV and HBV infections were
detected.
Imaging Findings:

- Chest X-Ray: Cardiac silhouette enlargement and opacification of the lower half of the left hemithorax

- Chest Ultrasound and Echocardiography: Pleural effusion with echoes and pericardial thickening as well as
complex pericardial effusion with echoes and septa (images not available)

- Chest CT: Necrotic mediastinal lymph nodes; large pericardial effusion with septa and irregular thickening of the
pericardium; large pleural effusion with nodular pleural thickening;random pulmonary micronodules

- Cardiac MRI: Necrotic mediastinal lymph nodes; large pleural effusion; large pericardial effusion with septa and
irregular thickening of the pericardium; signs of constrictive pericarditis
Discussion:

Background
- Tuberculous pericarditis, caused by Mycobacterium tuberculosis, is rare in developed countries, but is an important
aetiology of pericarditis in Africa, owing to the HIV epidemic.
- Pericardial involvement comes from lymphatic spread of M.tuberculosis from peribronchial, peritracheal, or
mediastinal lymph nodes or by hematogenous spread from primary tuberculous infection [1].

Clinical Perspective
- Tuberculous pericarditis presents clinically in 3 forms: pericardial effusion, constrictive pericarditis or a combination
of both.
- Tuberculous pericardial effusion presents with nonspecific symptoms, such as fever, night sweats, fatigue, and
weight loss. Chest pain, cough, and breathlessness are common.
- Patients with constrictive pericarditis present with symptoms of heart failure (dyspnoea, orthopnea, fatigability) and
may have liver enlargement and ascites.
- Pericardiocentesis is recommended in all patients in whom TB is suspected [1].

Imaging Perspective
- Chest radiograph may show an enlarged cardiac shadow (>90%), active pulmonary TB features (30%) and pleural
effusion (40-60%).
- Transthoracic echocardiography is the first-line technique for pericardial disease and to guide pericardiocentesis.
Effusion with fibrinous strands is typical but not specific [1].
- Chest CT and MRI enable detection of pericardial effusion and thickening of the pericardium, while showing
enlarged mediastinal lymph nodes, and parenchymal or pleural abnormalities [1]. CT is the best modality for
pericardial calcifications [2, 3]. Calcification is a nonspecific response to chronic inflammation, not a definite sign of
tuberculous aetiology [3].
- The diagnosis of constrictive pericarditis is aided by CT and MR. The typical appearance is thickening of the
pericardium +/- calcifications (>4mm); constrictive symptoms are required for diagnosis. Other imaging findings
include tubular-shape of the right ventricle, atrial enlargement, dilatation of the IVC, pleural effusion and ascites [2,
3].
- Cardiac MRI was performed to exclude other causes of right heart failure and coexistent restrictive
cardiomyopathy. It did not bring any additional information, besides confirming the findings.
- A definite diagnosis requires demonstration of tubercle bacilli in pericardial fluid or histologic section of the
pericardium. A probable diagnosis is based on unexplained pericarditis in a patient with tuberculosis elsewhere, a
lymphocytic pericardial exudate with elevated ADA activity or good response to a trial of antituberculosis
chemotherapy [4].

Outcome
- Treated with antituberculosis chemotherapy with or without pericardiectomy [4]. Preoperative CT and MRI allow
surgical planning [3].
- This patient started antituberculous chemotherapy and is continuing treatment in outpatient care. He is expected to
start antiretroviral therapy for HIV soon. No surgical treatment was needed until now.

Take Home Message, Teaching Points

- Tuberculous pericarditis should be considered in all cases of pericarditis without a rapidly self-limited course [1].
Differential Diagnosis List: Tuberculous Pericarditis (definite diagnosis), Tuberculous pericarditis, Pericardial
metastasis (namely from lung cancer), Pericardial mesothelioma

Final Diagnosis: Tuberculous Pericarditis (definite diagnosis)

References:

Mayosi, BM; Burgess LJ; Doubell AF (2005) Tuberculous Pericarditis. Circulation 112: 3608-3616 (PMID: 16330703)
Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW, Higgins CB (2003) CT and MR Imaging of Pericardial
Disease. RadioGraphics 23:S167–S180 (PMID: 14557510)
Bogaert J, Francone M (2013) Pericardial Disease: Value of CT and MR Imaging. Radiology Volume 267: Num
2—May 2013 (PMID: 23610095)
Syed FF, Mayosi BM (2007) A modern approach to tuberculous pericarditis. Progress in Cardiovascular Diseases
Nov-Dec;50(3):218-36 (PMID: 17976506)
Figure 1
a

Description: Chest X-Ray: Cardiac silhouette enlargement (blue arrow) and opacification of the left
hemithorax (orange arrow) Origin: Department of Radiology, Centro Hospitalar de Vila Nova de
Gaia/Espinho, Portugal
Figure 2
a

Description: Chest CT with i.v. contrast: Necrotic lymph nodes (blue arrow); pleural thickening with
pleural effusion (orange arrow) Origin: Department of Radiology, Centro Hospitalar de Vila Nova de
Gaia/Espinho, Portugal
Figure 3
a

Description: Chest CT with i.v. contrast: Irregular pericardial thickening (blue arrow), and large
pericardial effusion (orange arrow. Origin: Department of Radiology, Centro Hospitalar de Vila Nova de
Gaia/Espinho, Portugal
Figure 4
a

Description: Chest CT: Randomly distributed micronodules throughout the lung parenchymaOrigin:
Department of Radiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
Figure 5
a

Description: Cardiac MRI: Axial cine images show large pleural effusion (orange arrow), mediastinal
lymph nodes (green arrow), pericardial effusion with septa (blue arrow), and flattened right ventricle
(purple arrow) Origin: Department of Radiology, Centro Hospitalar de Vila Nova de Gaia/Espinho,
Portugal
Figure 6
a

Description: Cardiac MRI: Sagittal cine images show large pleural effusion (orange arrow), pericardial
effusion with septa (blue arrow), irregular thickening of the pericardium (green arrow), and flattening of
the right ventricle (purple arrow) Origin: Department of Radiology, Centro Hospitalar de Vila Nova de
Gaia/Espinho, Portugal