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Year : 2015  |  Volume : 1  |  Issue : 2  |  Page : 179-181

Treatment of tuberculosis pericarditis


Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication30-Sep-2015

Correspondence Address:
Dr. Alladi Mohan
Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-5414.166337

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  Abstract 

Tuberculosis (TB) is responsible for approximately 70% of the cases of large pericardial effusion and the most cases of constrictive pericarditis in developing countries. Early diagnosis and institution of appropriate therapy are critical to prevent mortality. Treatment of TB pericardial effusion consists of 4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months. Systematic reviews and meta-analyses suggest that although overall corticosteroids are associated with a beneficial effect on the variables analyzed, the wide confidence interval and a small number of events make it impossible to draw firm conclusions. Pericardiectomy is the definitive treatment for constrictive pericarditis, but is unwarranted either in very early constriction where it could be transitory.

Keywords: Pericarditis, treatment, tuberculosis


How to cite this article:
Harikrishna J, Mohan A. Treatment of tuberculosis pericarditis. J Pract Cardiovasc Sci 2015;1:179-81

How to cite this URL:
Harikrishna J, Mohan A. Treatment of tuberculosis pericarditis. J Pract Cardiovasc Sci [serial online] 2015 [cited 2019 Nov 18];1:179-81. Available from: http://www.j-pcs.org/text.asp?2015/1/2/179/166337


  Introduction Top


Tuberculosis (TB) pericarditis is an important form of extra-pulmonary TB that is associated with a high morbidity and mortality. If untreated, TB pericarditis will be associated with a high mortality (up to 90%) in the acute phase of the illness and leads to the development of constrictive pericarditis and rarely dissemination to other sites. TB constrictive pericarditis also contributes further to mortality. Institution of anti-TB treatment has been shown to substantially reduce the likelihood of occurrence of constrictive pericarditis as well as mortality in human immunodeficiency virus (HIV)-seropositive and seronegative individuals.[1],[2],[3] Therefore, early institution of appropriate therapy after diagnosis is essential.


  Antituberculosis Drugs Top


Regimen and duration

There are no trials specifically treating the patients with TB pericarditis that have assessed optimal drug combination and treatment duration. At present, available published evidence suggests that there are no biological reasons to believe that anti-TB drug treatment for TB pericarditis should be longer than the treatment of active TB elsewhere, and recommendations for current standard regimens seem appropriate.[4] The World Health Organization (WHO) guidelines [5] advocate the use of standard first-line anti-TB drugs, namely, isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E), in the combination of RHZE during the intensive phase of first 2 months, followed by a continuation phase of RH for the subsequent 4 months.

Dosing frequency

Almost all countries in the world daily use directly observed or self-supervised treatment, the Revised National TB Control Programme of Government of India (www.tbcindia.nic.in) as of now is using thrice-weekly intermittent treatment. The WHO guidelines [5] suggest that wherever feasible, the optimal dosing frequency for new patients with pericardial TB is daily throughout the course of therapy (strong/high grade of evidence for pulmonary TB). Thrice-weekly dosing throughout the treatment [2(HRZE)3/4(HR)3] may be used as an another alternative to the above recommendation, provided that every dose is directly observed and the patient is not living with HIV or living in an HIV-prevalent setting (conditional/high and moderate grade of evidence).[5]


  Corticosteroids Top


The role of adjunctive corticosteroid treatment in patients with TB pericarditis is controversial. Most of the published guidelines recommend the use of adjunctive oral corticosteroids for the treatment of TB pericarditis. However, the choice of corticosteroid preparation (prednisone, prednisolone, and methylprednisolone), route (oral, intravenous, and intrapericardial) dosage of administration, and tapering schedule has been variable.

A systematic review updated in 2002[6],[7] that included four trials with a total of 469 participants reported that overall corticosteroids are associated with a beneficial effect on all the variables analyzed, the wide confidence interval (CI), and a small number of events make it impossible to draw firm conclusions. A combined analysis of participants with effusive and constrictive pericarditis suggested that steroids may be associated with fewer deaths, but this could have arisen by chance (relative risk [RR] 0.65; 95% CI 0.36–1.16). Corticosteroid treatment was also associated with a significant reduction of 31% in the death or persistence of TB after 2 years (RR 0.69; 95% CI 0.48–0.98, 96 events). The group receiving steroids were associated with fewer morbid outcomes, but none were statistically significant (need for repeated pericardiocentesis [RR 0.45; 95% CI 0.20–1.05), need for pericardiectomy (RR 0.85; 95% CI 0.51–1.42).[6],[7]

A single, randomized controlled trial (RCT)[8] in HIV-positive patients also failed to show differences between the treatment groups. Steroids were associated with fewer deaths in HIV positive participants, but this was not statistically significant (RR 0.50; 95% CI 0.19–1.28). A subsequent publication that analyzed the efficacy of corticosteroids in TB pericarditis included the same studies and produced the same results.[9] A subsequent RCT [10] randomized 57 patients with suspected or confirmed pericardial TB (all of whom underwent pericardiocentesis) to receive corticosteroids or a placebo via intrapericardial infusion. All the patients enrolled were aged 17 or over and 37% of them were HIV-positive. No deaths were recorded at the 1-year follow-up. Two patients who received corticosteroids developed constrictive pericarditis due to the pericardial effusion.

A systematic review, meta-analysis [11] published in 2013, included six studies in patients with TB pericarditis showed that corticosteroid use was associated with a significant reduction in mortality and the results remained when trials that used rifampicin-containing regimens only were analyzed.

A recent RCT [12] evaluated the effects of adjunctive corticosteroid therapy and Mycobacterium indicus pranii immunotherapy in patients with TB pericarditis. There was no significant difference in the primary outcome between the patients who received prednisolone and those who received placebo (P = 0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (P = 0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (P = 0.009) and hospitalization (P = 0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer owing mainly to an increase in HIV-associated cancer.


  Pericardiectomy Top


Pericardiectomy is the definitive treatment for constrictive pericarditis but is unwarranted in very early constriction.[13] Constriction may be transitory with a course lasting weeks to a few months in the patients recovering from acute effusive pericarditis.[14] In these patients, the procedure should be delayed until it is certain that the constrictive process is not transitory. Symptom relief and normalization of cardiac pressures may take several months after pericardiectomy, but may occur sooner when the operation is performed before the disease is too chronic and when the pericardiectomy is almost complete.[15],[16],[17]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004;120:316-53.  Back to cited text no. 1
    
2.
Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation 2005;112:3608-16.  Back to cited text no. 2
    
3.
Syed FF, Mayosi BM. A modern approach to tuberculous pericarditis. Prog Cardiovasc Dis 2007;50:218-36.  Back to cited text no. 3
    
4.
Garner P, Holmes A. Treating tuberculosis. Clin Evid Concise 2002;7:146-7.  Back to cited text no. 4
    
5.
World Health Organization. Treatment of Tuberculosis. Guidelines. WHO/HTM/TB/2009.420. 4th ed. Geneva: World Health Organization; 2010.  Back to cited text no. 5
    
6.
Mayosi BM, Volmink JA, Commerford PJ. Interventions for treating tuberculous pericarditis. Cochrane Database Syst Rev 2000;2:CD000526.  Back to cited text no. 6
    
7.
Mayosi BM, Ntsekhe M, Volmink JA, Commerford PJ. Interventions for treating tuberculous pericarditis. Cochrane Database Syst Rev 2002;4:CD000526.  Back to cited text no. 7
    
8.
Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A. Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. Heart 2000;84:183-8.  Back to cited text no. 8
    
9.
Ntsekhe M, Wiysonge C, Volmink JA, Commerford PJ, Mayosi BM. Adjuvant corticosteroids for tuberculous pericarditis: Promising, but not proven. QJM 2003;96:593-9.  Back to cited text no. 9
    
10.
Reuter H, Burgess LJ, Louw VJ, Doubell AF. Experience with adjunctive corticosteroids in managing tuberculous pericarditis. Cardiovasc J S Afr 2006;17:233-8.  Back to cited text no. 10
    
11.
Critchley JA, Young F, Orton L, Garner P. Corticosteroids for prevention of mortality in people with tuberculosis: A systematic review and meta-analysis. Lancet Infect Dis 2013;13:223-37.  Back to cited text no. 11
    
12.
Mayosi BM, Ntsekhe M, Bosch J, Pandie S, Jung H, Gumedze F, et al. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis. N Engl J Med 2014;371:1121-30.  Back to cited text no. 12
    
13.
Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmüller R, Adler Y, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004;25:587-610.  Back to cited text no. 13
    
14.
Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL, Oh JK. Transient constrictive pericarditis: Causes and natural history. J Am Coll Cardiol 2004;43:271-5.  Back to cited text no. 14
    
15.
Seifert FC, Miller DC, Oesterle SN, Oyer PE, Stinson EB, Shumway NE. Surgical treatment of constrictive pericarditis: Analysis of outcome and diagnostic error. Circulation 1985;72 (3 Pt 2):II264-73.  Back to cited text no. 15
    
16.
Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB, et al. Constrictive pericarditis in the modern era: Evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999;100:1380-6.  Back to cited text no. 16
    
17.
Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, et al. Pericardiectomy for constrictive pericarditis: A clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques. Ann Thorac Surg 2006;81:522-9.  Back to cited text no. 17
    




 

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  In this article
   Abstract
  Introduction
   Antituberculosis...
  Corticosteroids
  Pericardiectomy
   References

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