A case report of a 24-year-old male with a large hemorrhagic pericardial effusion

JIN Jia-Lin, YANG Fei-Fei, ZHANG Wan-Qin, ZHANG Wen-Hong

Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China

A 24-year-old human immunodeficiency virus (HIV)-negative male patient was admitted on 26th March 2007, suffering from fever(temperature ranged between 38-39 ℃)，paroxysmal chest pain, dry nonproductive cough, anorexia, and fatigue for 9 d. Before admission, the patient was treated with antibiotics, including cefuroxime, levofloxacin, and ribavirin, for injection for one week in the outpatient clinic. However, the symptom of chest pain got worse, especially more apparent after activity. The patient had no history of tuberculosis (TB), diabetes, or immunosuppression.

Physical examination at admission revealed an alert man in acute distress. His temperature was 37.8 ℃, pulse rate was 110 beats/min, respiratory rate was 26 breaths/min, and blood pressure was 125/80 mmHg. Double lung breath sounds clear to auscultation. Percussion showed that the heart border was enlarged to the left, heart rate was 110 beats/min and regular. Meanwhile, low heart sound blunted at pericardium and no peripheral edema, cyanosis, pallor, icterus or hepatosplenomegaly were found.

Laboratory investigations revealed a white blood cell (WBC) count of 6.2×109/L, with polymorphs 67.1%, lymphocytes 19.1%; hemoglobin (Hb) of 132 g/L; platelet count of 235×109/L; and an erythrocyte sedimentation rate (ESR) of 49 mm/h. He was seronegative for HIV and the hepatic and renal function tests were within normal limits. The electrocardiogram (ECG) showed low voltage complexes with sinus tachycardia. Chest X-ray indicated cardiomegaly, with heart-chest ratio 0.63. Echocardiography showed a large pericardial effusion, surrounding the heart, reaching 3.8 cm thickness in some parts. Pericardiocentesis was performed immediately and an ultrasound-guided pigtail catheter was inserted. Over the next few days, 300 ml, 220 ml, 110 ml, and 50 ml samples of pericardial fluid were aspirated from the patient. The color of the fluid ranged from noncondensing dark red(hemorrhagic)to light bloody to straw-colored to light yellow. Samples from the pericardial fluid were prepared for biochemical, microbiologic, and pathologic examinations.

The drained fluid revealed transudes as the nucleated cells of 1 630×106/L, with polymorphs 43%, lymphocytes 48%, total protein 60 g/L. Cytology showed no malignant cells. Positive T-SPOT TB results, a T cell-based interferon (IFN)-γ release assay (IGRA) forMycobacteriumtuberculosisinfection indicated the infection of TB.

The patient was then given empirical anti-TB treatment. The treatment was initiated with 4 drugs, including isoniazid 600 mg/d, rifampicin 600 mg/d, pyrazinamide 1 500 mg/d, and ethambutol 750 mg/d. Meanwhile, anti-inflammatory drugs, including methylprednisolone 40 mg (tapered gradually), were also given. Fortunately, 2 d later, the Ziehl-Neelsen (ZN) stained smears showed acid-fast bacilli (AFB) of 7 bacteria/300 fields. Culture on Lowenstein-Jensen (LJ) media showed rough colonies suggestive ofMycobacteriumtuberculosisafter four weeks of incubation and was confirmed by acid-fast staining.

Treatment was continued for a period of 6 months with clinical follow-up. After only four weeks of therapy, significant clinical improvement was observed; the patient had a normal body temperature and no pericardial effusion was found under echocardiography examination. During the 1-year follow-up after treatment, no recurrence of symptoms was found.

Pericardial effusion is a common finding in clinical practice. A wide variety of conditions may result in pericardial effusion[1,2], including acute inflammatory pericarditis (infections or autoimmune diseases), previous unknown neoplasia, acute myocardial infarction, cardiac surgery, trauma, chest radiation, end-stage renal failure, etc. Hemorrhagic pericardial effusion is relatively unusual and often suggests trauma, metastatic malignant tumor or TB. It is more often reported closely associated with neoplasia. However, the relative prevalence of these etiologies largely depends on the geographic area，so epidemiologic considerations are very important[3]. In areas with a high prevalence of TB, such as China, which is ranked the second highest TB burden country in the world, pericardial effusion is regularly associated with TB. Of course, neoplasia and other possibilities need to be excluded in the meantime.

Tubercular pericarditis has variable clinical presentations. Before empiric treatment, the patient was given the examination of T-SPOT, which is sometimes valuable in TB diagnosis with high sensitivity[4]. However, the false positivity for diagnosing active TB should be considered in high TB burden countries, where a high number of latent infections may complicate diagnostic efficiency. However, T-SPOT provides a timely and useful indication of tuberculosis infection in patients who are at high risk and may direct additional appropriate examination, leading to an early diagnosis and initiation of appropriate empiric treatments[5].

Although the patient presented in the current report achieved a good clinical response to the empiric anti-TB drugs, the diagnosis of tubercular pericarditis remains to be confirmed by culture. Therefore, the establishment of diagnosis still relies on routine examinations, including the AFB test of tubercle bacilli in sputum or pericardial fluid. However, since negative AFB and culture results are common in clinical practice, the immune diagnostic assay as well as the response to empiric treatment can help to make the clinical diagnosis and may direct the whole course of continuous treatment, which usually needs at least 6 months.

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