Tuberculous pericarditis: causes, symptoms, diagnosis, treatment

Pericarditis is an inflammation of the membranes of the heart of infectious or non-infectious origin. Tuberculous pericarditis is an inflammation of the membranes of the heart caused by tuberculosis infection.

Pericarditis can be an independent and sole manifestation of any infectious disease, including tuberculosis, but more often it is a complication of a general widespread infectious or non-infectious process.

Epidemiology of tuberculous pericarditis

In recent years, the incidence of bacterial pericarditis has decreased significantly. Two causes are recognized as competing in this localization of the inflammatory process: tuberculosis and rheumatism. Literature data on the incidence of tuberculous pericarditis are highly contradictory, their share among all pericarditis is 10-36%. Particular attention should be paid to the increase in the incidence of pericarditis in patients with tuberculosis and HIV infection. Among patients with tuberculosis, 6.5% have an 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 can be limited or widespread. Symptoms of tuberculous pericarditis of this form are as follows: dull, pressing pain in the heart area; usually without irradiation. Circulatory disorders are rarely observed. A decrease in blood pressure is possible.

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

Chronic tuberculous pericarditis is most often observed in people aged 30-50 years and older. It is usually preceded by exudative-fibrinous (exudative-adhesive) pericarditis. In the first days from the onset of the inflammatory process, fibrin is deposited on both layers of the pericardium in the form of threads floating in the exudate ("hairy heart"). With an increase in the concentration of fibrin, the exudate becomes jelly-like, which in turn complicates diastolic relaxation of the myocardium and reduces the volume of ejection (minute volume, etc.). At the same time, fibrin deposits complicate the resorption of the exudate, the process can drag on for many months. In the chronic course of tuberculous pericarditis, cardiac tamponade almost never occurs. Symptoms of tuberculous pericarditis of this form are less pronounced and are manifested mainly by moderate pain behind the sternum, often not associated with physical exertion. Dyspnea is rarely observed and its occurrence is noted only during physical exertion. In this group of patients, pericardial friction rub is often heard.

Classification of pericarditis

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

• Sharp.
  • Dry (fibrinous).
  • Exudative:
    • with tamponade;
    • without tamponade.
  • Purulent and putrefactive.
• Chronic.
  • Exudative.
  • Exudative-adhesive (exudative-fibrinous).
  • Adhesive:
    • "asymptomatic";
    • with cardiac dysfunction:
    • with lime deposits ("armored heart");
    • with extrapericardial adhesions;
    • constrictive pericarditis (initial, severe, dystrophic stage).

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

Treatment of tuberculous pericarditis

Prevention of complications of tuberculous pericarditis includes, first of all, early diagnostics of this pathology in case of tuberculosis of intrathoracic lymph nodes. Echocardiographic examination is considered to be the most informative method of detection. To prevent the formation of adhesions, constrictive syndrome and "armored heart" in the early stages, treatment of tuberculous pericarditis requires the use of not only glucocorticoids, but also protease inhibitors [aprotinin (contrycal) and its analogues], as well as drugs that inhibit collagen synthesis (penicillamine (cuprenil)].

Exudate is removed when there is a risk of cardiac tamponade or when there is significant compression of the vena cava with the development of secondary complications. Pericardial puncture is performed along the parasternal line on the left in the fourth or fifth intercostal space or under the xiphoid process, the needle is led upward to the apex of the heart. Sometimes it is advisable to catheterize the pericardial cavity for the continuous removal of the fluid that is forming and to administer glucocorticoids and antibacterial drugs. In recent years, the pericardiotomy technique has become widespread, when exudate is removed surgically through an incision in the epigastric region. The advantage of this technique is that manipulations are performed under visual control, which makes it possible to perform a pericardial biopsy with subsequent morphological examination of the biopsy.

In chronic pericarditis, when some amount of exudate remains after the main course of chemotherapy, it is advisable to remove the fluid by pericardiotomy. Puncture is difficult to perform in these cases. It is important to remember that when transporting the exudate to the laboratory, heparin must be added to the container. In the case of repeated accumulation of fluid, as well as in the formation of an "armored heart" and in constrictive pericarditis, pericardiectomy is performed. Shunting of the pericardial cavity used by cardiac surgeons in pericarditis, if there is a suspicion of tuberculous pericarditis, is inappropriate due to the possible spread of the specific process to other organs.