HomeCommon presenting symptoms are nonspecific and result from the underlying infectious process (fever, night sweats), cardiac compromise (dyspnea, orthopnea) or disease elsewhere (eg, cough). Physical signs vary depending upon the degree of cardiac compromise.86,292 Early presentation is associated with a serosanguinous exudative pericardial effusion that may resolve spontaneously over a few weeks or may progress to cardiac tamponade or pericardial constriction.
Imaging modalities for TB pericarditis can include chest radiography, echocardiography, cardiac MRI or CT chest imaging.86,292 TB pericardial effusion is more likely than viral/idiopathic pericardial effusion if there is mediastinal lymphadenopathy on CT imaging; however, this does not assist with differentiation from malignant pericardial effusions.293,294
TB pericardial fluid is typically a bloody exudative effusion and often lymphocyte-predominant.84 However, similar findings can be found in chronic idiopathic and malignant pericardial effusions.295
Diagnosis of TB pericarditis can be confirmed with sampling of pericardial fluid (60% sensitivity) and/or pericardial tissue (90% sensitivity) for AFB smear, NAAT, culture and histopathologic analysis (Table 1). Given the difficulties in diagnosis and the high morbidity and mortality associated with this condition (80-90% mortality in the pre-antibiotic era), empiric treatment may need to be considered while awaiting the results of microbiologic/histologic testing (especially in the immunocompromised, as typical histopathology findings may not be present).296–298
3.8.1. TB pericarditis treatment
Treatment regimen/duration recommendations are based on observational data that has demonstrated a reduction in incidence of constrictive pericarditis and mortality compared to the pre-antibiotic era.82,84,296,299–301
In a Cochrane review that analyzed HIV-negative and people with HIV separately, corticosteroids significantly reduced the risk of death from pericarditis. In people with HIV, steroids did not significantly improve any clinical outcome. Of note, only 20% of the participants with HIV were taking antiretroviral medications. There was not a significant increase in opportunistic infections or malignancy among either People with HIV or HIV-negative participants, although the data are limited. There are minimal data for people with HIV on established antiretroviral treatment. In patients with good antiretroviral drug viral suppression, the data from HIV negative patients may be considered more applicable.296 An initial dose of prednisolone 120 mg PO daily with a taper over six weeks was prescribed in the largest and most recent study included in the 2017 Cochrane meta-analysis (Table 2).296,301
Recommendations
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We conditionally recommend six months of standard anti-TB therapy for treatment of drug-susceptible TB pericarditis (poor evidence).
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We conditionally recommend initial adjunctive corticosteroid treatment in all HIV negative patients with TB pericarditis (poor evidence).
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We conditionally recommend against routine use of adjunctive corticosteroids in people with HIV not on antiretroviral treatment (poor evidence).
Good practice statements
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We are unable to provide a specific recommendation on use of adjunctive corticosteroids in people with HIV who are on antiretroviral treatment with TB pericarditis given lack of data. We suggest assessing on a case-by-case basis pending further study.
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In patients with recurrent pericardial effusions or persistently elevated central venous pressures despite removal of pericardial fluid and use of anti-TB drugs, we suggest referral for consideration of early pericardiectomy.
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