Tuberculous pericarditis: causes, symptoms, diagnosis, treatment

Pericarditis - inflammation of the heart membranes of an infectious or non-infectious nature. Tuberculous pericarditis is an inflammation of the membranes of the heart caused by a tuberculous infection.

Pericarditis can be an independent and the only manifestation of any infectious disease, including tuberculosis, but is more often a complication of the common common infectious or non-infectious process.

Epidemiology of tuberculous pericarditis

In recent years, the number of bacterial pericarditis has significantly decreased. Competing for a given localization of the inflammatory process is recognized by 2 causes: tuberculosis and rheumatism. The literature data on the incidence of tubercular pericarditis are very contradictory, their share among all pericarditis is 10-36%. Particular attention should be paid to increasing the number of pericarditis in patients with tuberculosis with HIV infection. Among tuberculosis patients, 6.5% of patients note accumulation of exudate in the pericardial cavity.

[1], [2], [3], [4], [5], [6], [7]

Symptoms of tuberculous pericarditis

Dry pericarditis is the most common form. Dry pericarditis may be restricted or common. Symptoms of tuberculous pericarditis of this form are: dull, pressing pains in the region of the heart; as a rule, without irradiation. Circulatory disorders are rarely observed. It is possible to lower blood pressure.

Exudative pericarditis is most often observed with primary tuberculosis along with other paraspecific reactions. Painful sensations occur mainly in the initial stages of the disease and disappear with fluid accumulation. When the amount of fluid becomes significant (more than 500 ml), the pains arise again, are blunt and pressing. Irradiation of pain is rarely noted, but sometimes they can irradiate into the interlateral area or into the angle of the left scapula. The second most common complaint is shortness of breath, which first appears gradually, only with physical exertion, and then at rest.

Chronic tubercular pericarditis is more common in people 30-50 years of age and older. Usually it is preceded by exudative-fibrinous (exudative-adhesive) pericarditis. In the first days from the onset of the inflammatory process, fibrin is deposited on both pericardial sheets in the form of filaments floating in exudate ("hairy heart"). With increasing fibrin concentration, the exudate becomes jelly, which in turn makes diastolic relaxation of the myocardium more difficult and reduces the volume of ejection (minute volume, etc.). However, the deposits of fibrin complicate the resorption of exudate, the process can drag on for many months. With the chronic course of tuberculous pericarditis, cardiac tamponades almost never occur. Symptoms of tuberculous pericarditis of this form are less pronounced and are manifested mainly by moderate pain sensations behind the breastbone, which are often not associated with physical activity. Dyspnea is rarely observed and is noted only when exercising. In this group of patients, pericardial friction noise is often heard.

Classification of pericarditis

There are two classifications of pericarditis. According to the first, they are divided according to the etiologic factor, according to the second - according to clinical and morphological features, taking into account the rate of development of the pathological process, the nature of tissue reactions and outcomes. We quote the latter, since it allows us to formulate an expanded diagnosis of the disease. According to this classification, the following forms of pericarditis are distinguished:

• Sharp.
  • Dry (fibrinous).
  • Exudative (exudative):
    • with a tamponade;
    • without tamponade.
  • Purulent and putrefactive.
• Chronic.
  • Exudative.
  • Exudative-adhesive (exudative-fibrinous).
  • Adhesive:
    • "Asymptomatic";
    • with violation of cardiac activity:
    • with the deposition of lime ("carapaceous heart");
    • with extrapericardial fissures;
    • constrictive pericarditis (initial, pronounced, dystrophic stage).

[8], [9], [10], [11]

Treatment of tuberculous pericarditis

Prevention of complications of tubercular pericarditis includes, first of all, early diagnosis of this pathology with tuberculosis of the intrathoracic lymph nodes. The most informative method of detection is echocardiography. For the prevention of the formation of fusion, constrictive syndrome and "palpable heart" in the early stages of treatment of tuberculous pericarditis requires the use of not only glucocorticoids, but also protease inhibitors [aprotinin (countercrack) and its analogs], as well as drugs that inhibit the synthesis of collagen (penicillamine (kurenenil) ].

Removal of exudate is performed with a threat of cardiac tamponade or with significant compression of the hollow veins with the development of secondary complications. Puncture of the pericardium is carried out along the parasternal line to the left in the fourth or fifth intercostal space or under the xiphoid process, the needle is led upwards to the apex of the heart. Sometimes it is advisable to catheterize the pericardial cavity for permanent removal of the forming fluid and the administration of glucocorticoids and antibacterial drugs. In recent years, the technique of pericardotomy has become widespread, when the removal of exudate is performed operatively through a cut in the epigastric region. The advantage of this technique is that the manipulations are performed under the control of vision, which makes it possible to perform a pericardial biopsy followed by a morphological study of the biopsy.

With chronic pericarditis, when after the main course of chemotherapy a certain amount of exudate persists, it is advisable to remove the liquid by pericardotomy. Puncture in these cases is difficult. It must be remembered that when transporting the exudate to the laboratory, it is necessary to add heparin to the container. In the case of re-accumulation of fluid, as well as in the formation of a "carious heart" and with constrictive pericarditis, pericardectomy is performed. Used by cardiosurgeons in pericarditis, bypassing the pericardial cavity, if there is a suspicion of tuberculous pericarditis, is inappropriate because of the possible spread of a specific process to other organs.