Pericarditis purulenta por mycobacterium tuberculosis y streptococcus pneumoniae: revisión del tema, a propósito de un caso / Purulent pericarditis due to mycobacterium tuberculosis and streptococcus pneumoniae: case report and review

La pericarditis purulenta es una patología poco frecuente pero que conlleva alta mortalidad. En la era pre antibióticos, se observaba en pacientes con neumonía complicada y las cocáceas gram positivas eran los gérmenes frecuentemente involucrados. Por otro lado, la pericarditis tuberculosa representa el 1% del total de casos de tuberculosis, aunque es frecuente zonas endémicas, principalmente asociada a la infección por el virus de la inmunodeficiencia humana (VIH). Presentamos el caso de un paciente de 19 años, en situación calle, infectado con VIH, con diagnóstico de pericarditis purulenta, donde se demostró la co-infección de Mycobacterium tuberculosis y Streptecoccus pneumoniae en el pericardio. La pericarditis purulenta polimicrobiana es poco frecuente y la co-infección por los gérmenes mencionados es anecdótica. A pesar del tratamiento antimicrobiano, el aseo quirúrgico, los esteroides y la fibrinolisis intrapericárdica, esta patología tiene un pronóstico ominoso, en parte, debido a la condición basal de los enfermos que la padecen.

Purulent pericarditis is a rare disease with a high mortality rate. In the pre-antibiotic era it was observed as a complication in patients with pneumonia. Gram-positive coccaceae were the most commonly implicated bacteria. Tuberculous pericarditis represents 1% of all tuberculosis (TBC) cases, although it is common in endemic areas, associated with human immunodeficiency virus (HIV) infection. We present the case of a 19-year-old homeless, admitted with HIV and malnutrition, diagnosed with purulent pericarditis. Mycobacterium tuberculosis and Streptococcus pneumoniae were found as a cause of purulent pericarditis. Polymicrobial purulent pericarditis is a rare condition and co-infection with the bacteria previously mentioned is merely anecdotal. Despite antimicrobial treatment, surgical management, steroids, and intrapericardial fibrinolysis, this pathology has an ominous prognosis, due in part to the pre-existing condition of these patients.

Pericardite tuberculosa em paciente imunocompetente: relato de caso / Tuberculous pericarditis in an immunocompetent patient: case report

A pericardite tuberculosa é uma forma rara de apresentação de tuberculose extrapulmonar, sendo mais frequente em regiões endêmicas e em pacientes imunocomprometidos. O quadro clínico é na maioria das vezes insidioso, por vezes com sintomas inespecíficos ou com quadro de tamponamento cardíaco. O diagnóstico é feito pela análise do líquido pericárdico ou biópsia pericárdica e o tratamento é realizado com rifampicina, isoniazida, pirazinamida e etambutol. O presente caso relata uma paciente de 51 anos, imunocompetente, com quadro de febre e dispneia há 7 dias. Em tomografia de tórax foi identificado importante derrame pericárdico, sem repercussão hemodinâmica em ecocardiografia transtorácica. A paciente foi submetida à drenagem do derrame pericárdico, com diagnóstico de tuberculose pericárdica pela análise do líquido. Iniciado o tratamento com RHZE, com boa evolução clínica e seguimento ambulatorial.

Tuberculous pericarditis is a rare form of extrapulmonary tuberculosis, being more frequent in endemic regions and in immunocompromised patients. The clinical picture is most often insidious, sometimes with nonspecific symptoms or with cardiac tamponade. Diagnosis is made by analysis of pericardial fluid or pericardial biopsy, and treatment is performed with rifampicin, isoniazid, pyrazinamide, and ethambutol. The present case reports a 51-year-old patient, immunocompetent, with fever and dyspnea for 7 days. A chest tomography showed significant pericardial effusion, without hemodynamic repercussions on transthoracic echocardiography. The patient underwent drainage of the pericardial effusion, with a diagnosis of pericardial tuberculosis by fluid analysis. Treatment with RHZE was started, with good clinical evolution and outpatient follow-up.

Cardiac tamponade caused by tuberculosis pericarditis in renal transplant recipients / 대한외과학회지

A 50-year-old male, renal transplant recipient, was admitted with fever and chest discomfort. At admission, chest radiologic finding was negative and echocardiography showed minimal pericardial effusion. After 2 days of admission, chest pain worsened and blood pressure fell to 60/40 mmHg. Emergency echocardiography showed a large amount of pericardial effusion compressing the entire heart. Pericardiocentesis was performed immediately. Mycobacterium tuberculosis was isolated from pericardial fluid. Tuberculosis pericarditis should be considered as the cause of cardiac tamponade in renal transplant recipients, even with the absence of pericardial effusion in the initial study or suggestive history.

A Case of Tuberculosis-associated Hemophagocytic Syndrome during Antituberculosis Medication for Tuberculous Pericarditis / 결핵및호흡기질환

A 63-year old woman was admitted to our hospital for an evaluation of thrombocytopenia. She had been diagnosed with tuberculous pericarditis three months earlier in a local clinic and treated with anti-tuberculosis medication. Two months later, thrombocytopenia developed. The medication was subsequently stopped because it was suspected that the anti-tuberculosis medication, particularly rifampin, might have caused the severe platelet reduction. However, the thrombocytopenia was more aggravated. A bone marrow biopsy was performed, which showed moderate amounts of histiocytes with active hemophagocytosis. This finding strongly suggested that the critical thrombocytopenia had been caused by hemophagocytic syndrome, not by the side effects of the anti-tuberculosis medication. Furthermore, the development of hemophagocytosis might have been due to an uncontrolled tuberculosis infection and its associated aberrant immunity. Therefore, she was started with both standard anti-tuberculosis medication and chemotherapy using etoposide plus steroid. One month after the initiation of treatment, the thrombocytopenia had gradually improved and she was discharged in a tolerable condition. At the third month of the follow-up, her platelet level and ferritin, the activity marker of hemophagocytic syndrome, was within the normal range.