1351817 - An unusual case of tuberculous pneumopericarditis in immunocompetent patient

A 57-year-old man with a history of smoking and alcoholism. He was admitted to ER with  a history of  one month of progressive dyspnea, peripheral edema and ascities. On physical examination Heart rate: 90 bpm, respiratory rate: 18 bpm, blood pressure 92/65 mmHg, jugular vein distention, marked edema up to the thighs.

Diagnostic Techniques and Their Most Important Findings:

Echocardiogram showed moderate pericardial effusion. Computed tomography demonstrated parenchymal lung disease and thickened pericardium as well as non significant stenosis coronary (Figure 1A-E). CMR was performed with pericardial effusion and pneumopericardium. Control MRI after pericardial window was done, without residual pericardial effusion and tissue tethering at basal segments. STIR sequence demonstrated pericardial and myocardium edema, inversion recovery sequence demonstrated pericardial enhancement (Figure 2). Patient underwent pericardial window and biopsy, adenosine deaminase test, bacilloscopy and cultures were negative. Catheterization was performed with ‘square root’ sign in the RV pressure tracing with variation of end-diastolic pressure of the left and right ventricle of 5 mmHg, suggesting constrictive pericarditis (Figure 1F). The biopsy showed granulomas with Langhans-type cells and Koch's bacilli (Figure 3). The diagnosis of pericarditis due to Mycobacterium tuberculosis was done. Specific treatment was started however 2 weeks after he was readmitted due to severe pericardial effusion, then total pericardiectomy was indicated.

Learning Points from this Case:

We describe a rare case of incessant infectious pericarditis associated with spontaneous pneumopericardium caused by Mycobacterium tuberculosis. For the characterization of the pericardium, CMR was performed demonstrating anterior pneumopericardium and signs of pericardial constriction such as septal shudder and tissue tethering at basal segments. Pneumopericardium most commonly results from trauma. It is a rare entity and spontaneous pneumopericardium is even rarer. Micobacterium tuberculosis can affect any organ of the body and often presents with cardiac involvement. After the central nervous system, cardiovascular involvement is one of the most common extrapulmonary manifestations of tuberculosis. Pericardial compromise include pericardial effusion, myopericarditis, and constrictive pericarditis. Tuberculosis is the most common cause of constrictive pericarditis in endemic countries, accounting for 38% to 83% of the cases. Pericardial involvement is relatively common, especially in patients with AIDS where pericardial effusion caused by M tuberculosis reaches 85% or higher. Conversely, in immunocompetent patients with acute pericarditis, tuberculosis accounts for < 5% of cases. Transient constriction occurs in 10% of tuberculosis-related pericarditis, while progression to overt constrictive pericarditis occurs in 20% to 50% of patients despite being on antituberculosis treatment.