Tuberculosis Induced Pericarditis General Information A. Chief Complaint (CC) SOB, PND, DOE > ½ mile, 2 Pillow Orthopnea History of Present Illness (HPI)
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Tuberculosis is usually classified as either pulmonary or extra pulmonary
Proper isolation in a negative-pressure room.. Health department notified of all cases of TB, contacts identified, compliance with therapy can be ensured by directly observed therapy (DOT)
At least two drugs to which the organism is susceptible must be used because of the high frequency with which primary drug resistance to a single drug develops.
INH (5 mg/kg; maximum, 300 mg PO qd),
RIF (10 mg/kg; maximum, 600 mg PO qd),
pyrazinamide (PZA, 15–30 mg/kg PO qd),
and either ethambutol EMB, 15 mg/kg PO qd) or streptomycin (15 mg/kg; maximum, 1.5 g IM qd)
If the isolate proves to be fully susceptible to INH and RIF, EMB (or streptomycin) can be dropped and INH, RIF, and PZA continued to finish 8 weeks, followed by 16 weeks of INH and RIF. After at least 2 weeks of daily therapy, the medications can be administered twice a week at adjusted doses.
When INH resistance is documented, the INH should be discontinued, and the remaining three drugs should be continued for the duration of therapy.
Therapy should include at least three drugs to which the organism is susceptible. Careful documentation of bacteriologic sputum culture conversion is important, and therapy should be continued for at least 12 months and possibly as long as 24 months after cultures convert to negative.
3.Extrapulmonary disease in adults can be treated in the same manner as pulmonary disease, with 6- to 9-month short-course regimens.
B.Monitoring. Patients with pulmonary TB whose sputum smears are positive before treatment should submit sputum for acid-fast bacilli smear and culture every 1–2 weeks until smears become negative.
C. Adverse reaction monitoring. Baseline laboratory evaluation at the start of therapy that includes ASL,ALT, bili, CBC, SCr level.
D.Glucocorticoid administration. In TB, the administration of glucocorticoids is controversial. Prednisone, 1 mg/kg PO qd initially, has been used in combination with antituberculous drugs for life-threatening complications such as meningitis and pericarditis.
III. Chemoprophylaxis. Untreated, approximately 5% of persons with latent TB infection (LTBI)develop active TB disease within 2 years of infection. An additional 5% will develop TB disease during their lifetime.
A.Criteria for a positive TST are (1) 5-mm induration in patients with HIV infection or another defect in cell-mediated immunity, close contacts of a known case of TB, patients with chest radiographs typical for TB, and patients with organ transplantation or other immunosuppression (>15 mg/day prednisone for >1 month); (2) 10-mm induration in immigrants from high-prevalence areas (Asia, Africa, Latin America, Eastern Europe), prisoners, the homeless, parenteral drug abusers, nursing home residents, the medically underserved, low-income populations, patients with chronic medical illnesses, and those people having frequent contact with these groups (e.g., health care workers, prison guards); and (3) 15-mm induration in individuals who are not in a high-prevalence group).
B.Prophylactic therapy (treatment for LTBI) should be administered only after active disease has been ruled out by a proper evaluation (chest radiography, sputum collection, or both). INH, 300 mg PO qd for 9 months,
Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients(HEART 1 August 2000)
OBJECTIVE: Eeffect of adjunctive prednisolone on morbidity, mortality in HIV seropositive patients with effusive tuberculous pericarditis.
DESIGN: Placebo controlled double blind randomised.
SETTING: Harare, Zimbabwe medical schools
PATIENTS: 58 HIV seropositive and tuberculous pericarditis positive patients aged 18–55
INTERVENTIONS: All patients received standard short course antituberculous chemotherapy and received prednisolone or placebo for six weeks.
rifampicin, isoniazid, pyrazinamide, and ethambutol for two months, followed by rifampicin and isoniazid for a further four months in standard doses
Prednisolone and placebo were made as identical “5 mg” tablets. The intervention consisted of prednisolone/placebo tablets starting at a dose of 60 mg (12 tablets) and tapering by 10 mg per week until completion at the end of the sixth week.
MAIN OUTCOME MEASURES: Improved clinically, ECG, radiologic pericardial fluid resolution, and death.
RESULTS: 29 patients were assigned to prednisolone and 29 to placebo. After 18 months of follow up there were five deaths in the prednisolone treated group and 10 deaths in the placebo group. Mortality was significantly lower in the prednisolone group, hepatomegaly, ascites.. However, there was no difference in the rate of radiologic and echocardiographic resolution of pericardial effusion.
CONCLUSIONS: Adjunctive prednisolone for effusive tuberculous pericarditis produced a pronounced reduction in mortality. It is suggested prednisolone should be added to standard short course chemotherapy to treat HIV related effusive tuberculous pericarditis.
Controlled Clinical Trial of Complete Open Surgical Drainage and of Prednisolone in Treatment of Tuberculois Pericardial Effusion in Transkei (Lancet Oct 1988)
OBJECTIVE:To compare of open surgical drainage of pericardial fluid compared with early and open percutaneous pericardiocentisis when required and the role of prednisolone compared to placebo.
DESIGN: Double blind placebo controlled
SETTING:South Africa Medical Centers
PATIENTS: INTERVENTIONS. 240 patients with active TB pericardial effusions received a 4 drug antiTB regiment for 6 months followed for 24 months and given random surgical drainage of pericardial fluid, percutaneous pericardiocentisis and randomly given prednisolone or placebo for 11 weeks.
MAIN OUTCOME MEASURES: End point was death of subjects
RESULTS:During the 24 months, 3 % prednisolone and 14% of the placebo group died
CONCLUSIONS: Cortical steroids increase the rate of clinical improvement in conjunction with TB medication and probably reduce the rate of death and the decision of a pericardectomy
Relevance of Adenosine Deaminase and Lysozyme Measurements in the Diagnosis of TB Pericarditis (General Cartiology 2000)
OBJECTIVE: To assess the value of pericardial fluid Adenosine Deaminase (ADA) and Lysozyme (Lys)as a measure of TB Pericarditis
DESIGN: Paired wise comparisons prospective study of three separate groups different pericarditis
SETTING Single hospital Athens Greece
PATIENTS: 41 Patients ranging from age 17-77 into three groups TBP, with neoplastic TBP, and Idiopathic TBP
MAIN OUTCOME MEASURES: ADA and Lys pericardial levels
RESULTS:Ada levels >_ 72U/I and Lys >_ 6.5ug/dl were indicators of sensitivity of diagnostic TB pericarditis
CONCLUSIONS: prognosis of outcome decreased with ADA level
Catanzaro, AntoninoThe Role of Clinical Suspicion in Evaluating a New Diagnostic Test for Active Tuberculosis:Results of a Multicenter Prospective Trial JAMA Volume 283(5) 2 February 2000 pp 639-645
Constadina Aggeli Revenace of ADA and Lys Measurements in the Diagnosis of Tuberculosis Pericarditis Cardiology 2000; 94:81-85
Hakim, J G Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patientsHEART Volume 84(2)1 August 2000 pp 183-188