Constrictive Pericarditis Due to Pulmonary Tuberculosis

Herwindo Ahmad

, Zainal Safri

, Refli Hasan

, Rahmad Isnanta

Division of Cardiology, Department of Internal Medicine, Faculty of Medicine,

Universitas Sumatera Utara, Jalan Doktor Mansyur No. 5, Medan, Indonesia

Keywords: Pulmonary Tuberculosis, Constrictive Pericarditis.

Abstract. Background. Pericardium disease can occur due to abnormalities of the pericardium itself or as a result of

systemic disease. One of the diseases that can occur in the pericardium is the constrictive pericarditis

characterized by visceral and parietal pericardium layer attachment. Tuberculosis (TB) is a major cause of

constrictive pericarditis in developing countries. Case report. A 21-year-old complaints were pain like

being stabbed on the left chest, easily tired, swollen legs, cough and weight loss. Chest X-ray examination

were cardiomegaly and infiltrates. Echocardiography examination found pericardium effusion, constrictive

pericarditis with decreased function of cytolic and diastolic left ventricle. Mantoux Text showed positive

results. The treatments were antibiotics, diuretics, antituberculous drugs and steroids. Discussion.

Constrictive pericarditis is a chronic process of pericardium fibrous thickening that inhibits diastolic filling

of the heart, decreases venous return and decreases cardiac output. The diagnosis of constrictive pericarditis

is based on the association between clinical manifestation and from the results of one or more imaging

studies. Medical therapy has a role in the treatment of specific causes, anti-inflammatory, and supportive

effects. Conclusion. We reported a case of constrictive pericarditis due to pulmonary TB.

1 INTRODUCTION

The pericardium has several important functions

such as restricting the stretch or distention of the

cardiac cavity and facilitating the interaction of the

ventricles and the atrium so that changes in pressure

and volume in one part of the heart can affect

pressure and volume in other parts of the heart.

Pericardium also serves as a barrier to the spread of

infection and friction from the tissues surrounding

the heart. Although the pericardium has many

important functions but on the condition that the

pericardium is not found it is reported to have no

significant adverse effects (Francis, 2011).

Pericardium disease can occur due to abnormali-

ties of the pericardium itself or as a result of systemic

disease. Some diseases that can occur in the

pericardium such as pericarditis (acute, subacute,

chronic and recurrent), pericardium effusion, cardiac

tamponade and constrictive pericarditis (Adler, 2015).

Constrictive pericarditis is characterized by

diastolic cardiac filling disorder and increased

ventricular filling pressure due to rigid pericardium

with visceral and parietal pericardial layer

attachment. The symptoms of constrictive

pericarditis are the symptoms of heart failure with

increased jugular venous pressure, shortness of

breath, peripheral oedem, hepatomegaly, and ascites.

Tuberculosis is a major cause of constrictive

pericarditis in developing countries where the

incidence of tuberculosis is still high, but the

incidence in the developed countries is still rare

(Adler, 2015), (Dal-Bianco, 2009), (Lewinter, 2012).

2 CASE REPORT

A 21-year-old man went to the heart center

emergency department on August 2016 with a main

complaint of chest pain. Chest pain was felt by the

patient since 5 days, felt like being stabbed on the

left chest without spreading, nausea, vomiting or

cold sweat. Pain was felt to be more severe if the

patient inhales. Patients also complain of fatigue

easily during the activity within 2 weeks. Swollen

legs were found within 3 days. Cough has been

found since 6 months with white sputum without

blood. Patients admitted weight loss in the last 6

months as much as 10 kg with decreased appetite.

Fever, history of fever, history of shortness of

444

Ahmad, H., Safri, Z., Hasan, R. and Isnanta, R.

Constrictive Pericarditis Due to Pulmonary Tuberculosis.

DOI: 10.5220/0010072504440448

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

444-448

ISBN: 978-989-758-449-7

breath, hypertension, diabetes mellitus, smoking,

and drinking alcohol were denied by the patient.

On physical examination, sensorium alert, blood

pressure 100/70 mmHg, pulse 144 times/minute,

regular, pressure and volume enough, respiratory

rate 28 times/minute, body temperature 36.7 ° C.

Pale conjunctiva and icteric sclera was not found.

Increase of jugular vein pressure was found,

kussmaul sign (+). Heart sound S1 and S2 was

normal, murmur (-), gallop sound (-). Lung:

vesicular respiratory sound, rales or wheezing was

not found. Abdomen: soepel. Liver, lien, renal were

not palpable, peristaltic (+) normal. Extrimities:

warm acral, oedem pretibial was found on both legs.

From laboratory test: Hb: 12,4 g%; Ht 39%;

Leucosytes 13.220/mm

; PLT 328.000/mm

; Ur: 17

mg/dL; Cr 0.59mg/dL; Na 138 mEq/L; K 3.5

mEq/L; Cl 107 mEq/dL; Albumin 2.7 g/dL; Blood

Glucose adr 161 mg/dL, ASTO <200; CRP 0.7

mg/dL. The patient had done electrocardiographic

(ECG) and Chest X-Ray examination (Figure 1), the

conclusions from echocardiography examination and

Doppler Tissue Imaging were pericardiac effusion

and constrictive pericarditis (Figure 2 and Figure 3).

Figure 1: The ECG and Chest X-Ray of the Patient. The

impressions of (ECG) examination were sinus tachycardia

and LVH. Cardiomegaly and infiltrates were found on

Chest X-Ray examination.

The patient was diagnosed with constrictive

pericarditis, mild pericardiac effusion due to suspect

pulmonary tuberculosis and was consulted to the

pulmonologist. Interpretation of mantoux test was

27mm induration, redness (+), itchy (+), conclusion:

a positive result. Sputum culture results: Direct

smear of tuberculosis I and II was negative.

Figure 2: The Echocardiography Results of the Patient.

Constrictive Pericarditis Due to Pulmonary Tuberculosis

445

Figure 3: Doppler Tissue Imaging of the Patient. The e'

medial velocity was 25 cm/s and the e’ lateral velocity was

lower (9 cm/s). There was an increase in the difference of

mitral flow rate during inspiration and expiration > 25%.

There was also an increase in backflow of diastolic hapatic

veins at expiration.

Treatments of this patient were bed rest, O2 2-4

L/min with nasal canule, IVFD NaCl 0,9% 10

gtt/min, Cefotaxime 1 gr/8 hours/i.v, Gentamicin

120 mg/12 hours/i.v, anti-tuberculosis first category

drugs (Fixed Dose Combination) 1x3 tab,

prednisone 3x20 mg/oral, furosemide 1x40 mg/oral,

paracetamol 3x500 mg/oral, vitamine B6 1x2 tab.

There was clinical improvement after treatment for

14 days and the patient can get outpatient control.

Heart spaces

and

large blood vessels in the normal

position. Heart valves are good. There is no defect in the

heart chambers. There is a thickening of the pericardium

parietal and visceral with adhesion of the pericardium in

some places. There is a light pericardium effuse. The

systolic and diastolic function of LV decreases.

3 DISCUSSION

Constrictive pericarditis is a chronic process of

pericardium fibrous thickening which is often

followed by calcification and inhibition of diastolic

filling of the heart, decreasing venous return and

decreasing cardiac output. Constrictive pericarditis

is caused by a chronic inflammatory process of the

pericardium that triggers scar formation, fibrosis and

calcification in the pericardium. The incidence rate

of tuberculosis pericarditis is < 4% of pericardium

disease cases in developed countries but far different

when compared with developing countries that is 50-

70% of cases without HIV disease and > 90% in

cases accompanied by HIV disease, especially in

endemic areas for tuberculosis. In developed

countries the most frequent causes are idiopathic,

postoperative, radiation effects. In developing

countries, tuberculosis is the leading cause of

constrictive pericarditis (Adler, 2015; Lewinter,

2012; Little, 2006). In this case, the patient is

diagnosed with pulmonary tuberculosis where

tuberculosis is the most common cause of

constrictive pericarditis in developing countries

including Indonesia.

Constrictive pericarditis is characterized by

diastolic ventricular filling disorder resulting from

pericardium disease. Typical clinical features are

signs and symptoms of right heart failure with good

left and right ventricular function without any

myocardial or other ballast disease. Patients

complaint of fatigue, peripheral edema, shortness of

breath and ascites. Venous congestion, pleural

effusion, hepatomegaly may also occur (Adler,

2015; Mayosi, 2005).

On physical examination we can find an increase

in jugular venous pressure. Kusmmaul sign, ie

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

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increased venous pressure during inspiration or no

decrease in venous pressure during inpiration, can

also be encountered. Pulsus paradoxus occurs in a

third of cases, especially in pericarditis patients

followed by pericardium effusions. Another typical

sign that can be encountered is the pericardial knock

that arises during the initial diastolic phase due to

the sudden cessation of ventricular filling. On

abdominal examination we can find hepatomegaly

and liver congestion symptoms such as ascites and

jaundice. Oedem in both lower extremities is the

most common in cases of constrictive pericarditis

(Lewinter, 2012), (Talreja, 2008).

In this patient, the main complaints were chest

pain, fatigue, cough, and weight loss weight loss.

The results of physical examination were

tachycardia, increase in jugular venous pressure,

kussmaul sign and pretibial oedem on both legs.

The diagnosis of constrictive pericarditis is based

on the association between signs and symptoms of

right heart failure with diastolic filling disturbance

resulting from constriction in the pericardium from

the results of one or more imaging studies, including

echocardiography, CT, CMR and cardiac

catheterization (Adler, 2015), (Liu, 2009).

Low QRS voltage, nonspecific T-wave changes

and P mitral are common but ECG results are not

specific for the diagnosis of constrictive pericarditis.

On examination of chest X-ray the size of the heart

can be normal or enlarged. Echocardiographic

examination is very important to establish the

diagnosis of constrictive pericarditis (Francis, 2011).

The diagnosis of echocardiography in

constrictive pericarditis is based on findings from

M-mode echocardiography followed by 2D

echocardiography and Doppler hemodynamics in the

respiratory cycle response. In constrictive

pericarditis, the initial mitral inflow diastolic

decreases as inspiration and the isovolumetric

relaxation period elongated. While at expiration, the

mitral inflow returns to normal and the

isovolumetric relaxation retracts. Typical findings of

constrictive pericarditis are an increase in the rate of

mitral inflow in the early diastolic phase by as much

as> 25% during expiration compare with inspiration.

The hepatic venous flow from Pulsed Doppler in

constrictive pericarditis indicates a significant

diastolic flow reversal, which increasing in

expiration over inspiration (Dal-Bianco, 2009)

Doppler Pulsed Tissue examination and color

Doppler Tissue Imaging (DTI) may help to diagnose

constrictive pericarditis. The lateral or septal mitral

anular velocity at baseline > 8 cm/s is said to be the

boundary value for differentiating patients with

constrictive parikarditis and restrictive

cardiomyopathy. This examination is useful when

the initial diastolic mitral flow rate change is not

(Dal-Bianco, 2009), (Vaitkus, 1996).

In this patients the diagnosis of constrictive

pericarditis in addition to anamnesis and physical

examination, also obtained from an ECG

examination that shows sinus tachycardia and LVH.

From the results of chest X-ray obtained

cardiomegaly and found the infiltrate in the left lung

field. On mantoux test examination was found

positive results so that patients are also diagnosed

with pulmonary TB. This patient's

echocardiographic examination was in accordance

with the features of constrictive pericarditis.

Although the main management of constrictive

pericarditis is surgery, medical therapy has a role in

management at least in three conditions. First,

medical therapy for specific causes eg pericarditis

due to tuberculosis. Secondly, medical therapy such

as anti-inflammatory can treat transient constrictive

that occurs in 10-20% of cases within a few months,

generally in temporary phenomenon at the time of

resolution of pericarditis. Third, medical therapy is a

supportive therapy and aims to control congestion

symptoms in which surgery is contraindicated or at

high risk. Anti-tuberculosis drugs can reduce the risk

of 10-80% of occurrence of constrictive pericarditis

due to tuberculosis infection (Adler, 2015; Liu,

2009).

In this patient, the therapy given were antibiotics

(cefotaxime and gentamicin) and steroids namely

prednisone and antituberculosis drug. Patients have

not planned for pericardiotomy surgery.

4 CONCLUSIONS

A 21-year-old male patient with a diagnosis of

constrictive pericarditis due to pulmonary TB has

been reported. The diagnoses were established on

the basis of history, physical examination and

support of ECG, thoracic X-ray, echocardiography

examination, and mantoux test.

Constrictive pericarditis is characterized by

diastolic heart filling disorder and an increase in

ventricular filling pressure due to rigid pericardium

by adhering to the visceral and parietal pericardium.

Tuberculosis is a major cause of constrictive

pericarditis in developing countries where the

incidence of tuberculosis is still high.

Constrictive Pericarditis Due to Pulmonary Tuberculosis

447

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