Ann Thorac Surg 1998;65:542
© 1998 The Society of Thoracic Surgeons
Case Reports
A Late Complication of Tuberculous Pericarditis After Partial Pericardial Resection
Anita K. Gregory, MD,
Cliff P. Connery, MD,
Constantinos E. Anagnostopoulos, MD
Division of Cardiothoracic Surgery, Department of Surgery, St. Luke’s-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York, USA
Accepted for publication September 14, 1997.
Dr Connery, Division of Cardiothoracic Surgery, Department of Surgery, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Ave, New York, NY 10025.
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Abstract
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Tuberculous pericarditis is estimated to occur in 1% to 2% of cases of pulmonary tuberculosis. Despite adequate therapy, a subset of patients may eventually require pericardiectomy. Incomplete pericardial resections are associated with an increased incidence of late complications. We report a cutaneous sinus tract communicating with residual pericardium and a retrosternal abscess cavity 11 years after partial pericardial resection.
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Introduction
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Despite the decline in mortality due to tuberculosis and an overall decrease in the annual new case rate, tuberculosis remains a serious health problem. This is especially true in large urban areas in the United States, where case rates are nearly two and a half times greater than the national average. More than 22,000 cases were reported in 1995 [1], and a recent resurgence has been linked to the introduction of acquired immunodeficiency syndrome into the population [2].
Although the incidence of pulmonary tuberculosis has demonstrated a yearly decline, the incidence of extrapulmonary disease has remained relatively constant at 4,000 cases per year [3]. The heart is involved infrequently. Treatment of tuberculous (TB) pericarditis consists of conventional anti-TB drugs. The use of corticosteroids remains controversial. Despite adequate drug therapy, as many as one third to one half of patients will eventually require pericardiectomy [4]. Incomplete resections have been associated with an increased incidence of complications. We report an unusual late complication 11 years after partial pericardiectomy for effusive tuberculous pericarditis.
A 50-year-old male former intravenous drug abuser presented to the surgical clinic in May 1994 with a left anterior chest wall abscess and history of fever and weight loss. Tests for human immunodeficiency virus and sputum acid-fast bacilli were negative. The patient had a history of TB pericarditis in 1983 treated at another institution with isoniazid and rifampin. Due to persistent pericardial effusion, he underwent partial pericardiectomy via a left anterolateral thoracotomy at that time. Constrictive disease or features of tamponade were not present.
Incision and drainage liberated purulent fluid, which was acid-fast bacilli smear and culture negative. A recurrent abscess several months later necessitated further drainage and excision of the left eighth costal cartilage. A persistent draining sinus tract developed in this region. A bone scan showed no evidence of underlying osteomyelitis.
Computed tomographic examination of the chest showed calcification of the inferior pericardium with a significant right atrial calcified abscess cavity (Fig 1). Contrast injection via an 8F catheter showed a tract passing through the diaphragm, across the midline, which communicated with the aforementioned abscess cavity and residual pericardium (Fig 2). Transesophageal echocardiography revealed normal left ventricular function with an estimated ejection fraction of 0.55 and no pericardial effusion.
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Contrast injection of the fistula opening, demonstrating a fistula tract that passes through the diaphragm, across the midline, to communicate with residual pericardium and abscess cavity.
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The patient underwent elective resection and drainage via median sternotomy. Femorofemoral cardiopulmonary bypass was used to facilitate resection of the posterior pericardium and a portion of the right atrium, which was involved in the calcific sinus tract. The resultant defect along the diaphragmatic and right atrial surface was filled with a portion of greater omentum that had been mobilized from the peritoneal cavity. Abscess fluid sent for culture grew Staphylococcus aureus. No acid-fast bacilli were identified on smear or culture of the fluid or pericardium. The patient was treated with a 7-day course of intravenous vancomycin and recovered uneventfully. At 2-year follow-up, the patient reports no fevers and a 4.5-kg weight gain. No recurrent abscess cavity or sinus tract is noted on physical examination.
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Comment
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Tuberculous pericarditis is estimated to occur in 1% to 2% of cases of pulmonary tuberculosis [5]. Before the introduction of anti-TB medication in 1945, TB pericarditis was often rapidly fatal. The source of the mycobacterium in TB pericarditis remains unclear, with less than half of the patients having evidence of pulmonary tuberculosis. Retrograde spread from mediastinal or hilar lymph nodes may be responsible. Without chemotherapy, constriction will develop in virtually all patients. Even with anti-TB treatment, 30% to 50% of patients will progress to effusive or constrictive pericarditis, myocarditis, or tamponade [6]. For these reasons, many authors advocate early pericardiectomy.
Sonneberg and Parker [7] advocated early pericardiectomy for young patients with effusive TB pericarditis because of the low morbidity and significantly decreased risk of late pericardial constriction (0.85%) compared with those without pericardiectomy (17%). Data reported by DeValeria and colleagues [8] show a 97% survival rate when complete pericardiectomy is performed early in patients with effusive disease and good left ventricular function. Despite these favorable results, considerable controversy still exists in the literature with regard to the extent of necessary resection.
Although our patient’s condition did not progress to constrictive disease, his residual pericardium became calcific, serving as a nidus for bacterial infection, likely related to frequent episodes of bacteremia from his prior intravenous drug use. This created a persistent retrosternal abscess cavity and resultant draining sinus. This unusual late complication is likely a consequence of incomplete initial pericardial resection.
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References
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Summary of notifiable diseases, United States 1995. MMWR Morb Mortal Wkly Rep 1996;44(53):1–87.
- Porter JDH, McAdam KPWJ The re-emergence of tuberculosis. Ann Rev Public Health 1994;15:303-323.[Medline]
- Mehta JB, Dutt A, Harvill L, Mathews KM Epidemiology of extrapulmonary tuberculosis. A comparative analysis with the pre-AIDS era. Chest 1991;99:1134-1138.[Abstract/Free Full Text]
- Sagrista-Saleuda J, Permanyer-Miralda G, Soler J Tuberculous pericarditis: ten year experience with a prospective protocol for diagnosis and treatment. J Am Coll Cardiol 1988;11:724-728.[Abstract]
- Larrieu AJ, Tyers GFO, Williams EH, et al. Recent experience with tuberculous pericarditis. Ann Thorac Surg 1980;29:464-468.[Abstract]
- Long R, Younes M, Patton N, et al. Tuberculous pericarditis: long-term outcome in patients who receive medical therapy alone. Am Heart J 1989;117:1133-1139.[Medline]
- Sonneberg FA, Parker SG Elective pericardiectomy for tuberculous pericarditis: should the snappers be snipped?. Med Decis Making 1986;6:110-123.
- DeValeria PA, Baumgartner WA, Casale AS, et al. Current indications, risks, and outcome after pericardiectomy. Ann Thorac Surg 1991;52:219-224.[Abstract]
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Abstract
Introduction
