Episode 72
72: Total Effusion of the Heart
Turn around and listen to the bright minds of Drs. Annie Jacobs and Christopher Polk investigating two cases of pericardial effusion in the US and Kenya
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Transcript
Hey everyone.
Sara Dong:Welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:We use consult questions to dive into ID clinical reasoning, diagnostics and antimicrobial management.
Sara Dong:I'm Sara, your host, and a Med-Peds ID fellow.
Sara Dong:I'll introduce our co-host today, Dr.
Sara Dong:Annie Jacobs, who you may remember from the ID week 2022 episode.
ine resident at Atrium Health:Carolinas Medical Center in Charlotte, North Carolina.
ine resident at Atrium Health:She recently successfully completed the ID match process and will be starting her ID fellowship at UT Southwestern in July.
Annie Jacobs:Hey, Sara.
Sara Dong:Glad to have you back, Annie.
Sara Dong:All right, and our guest discussant today is Dr.
Sara Dong:Christopher Polk.
Sara Dong:He is an Associate Professor of Medicine and Assistant Specialty Director of Infectious Diseases Research in the Division of ID at Atrium Health, Wake Forest School of Medicine in Charlotte, North Carolina.
Sara Dong:His research interest include COVID-19, CRE producing infections, and HIV.
Christopher Polk:Good to be here.
Sara Dong:So before we get to the cases today, we like to call Febrile a cultured podcast and ask if you would be willing to share a little piece of culture that you have enjoyed recently.
Sara Dong:What do you guys got for today?
Annie Jacobs:So I have been binging on true crime podcasts lately, and I have discovered one called Disappearances by Sarah Turney.
Annie Jacobs:It takes you through a variety of people that have gone missing throughout history, sometimes with a very clear suspect and sometimes more ambiguous.
Annie Jacobs:And I highly recommend it to anyone that enjoys stoking their anxiety with a little bit of true.
Christopher Polk:So I actually don't listen to podcasts much with one exception, and, and the time I listen
Christopher Polk:is during my limited hobbies, which are running and hiking and, and so I like to do long runs.
Christopher Polk:I've done some marathons and, and during that I will listen to febrile.
Sara Dong:Oh, thanks.
Christopher Polk:My favorite podcast.
Sara Dong:Well, we have some, we're doing things a little bit differently today, and not just having one case, but more than one.
Sara Dong:Uh, so Annie, I'm gonna throw it over to you.
Annie Jacobs:Perfect.
Annie Jacobs:Our first case is a patient who presented to our urban hospital in North Carolina.
Annie Jacobs:He's a 70 year old man with a medical history of hypertension and gastric cancer status post fresection andning chemotherapy well over 10 years ago.
Annie Jacobs:He presented with one week of progressive cough and shortness of breath.
Annie Jacobs:He tells us that two years ago he had a Covid 19 infection, and since then he's had some dyspnea on exertion, but it's gotten significantly worse over the past one week.
Annie Jacobs:It is to the extent that he's unable to ambulate around his home without feeling significantly short of breath.
Annie Jacobs:His cough started about two weeks ago and it was initially dry though in the past two days, he's been coughing up a small amount of clear sputum.
Annie Jacobs:On further history, he shares that his breathing has been worse when laying down and he has to sleep with the head of his bed elevated.
Annie Jacobs:He denies any other preceding or concomitant symptoms including nausea, diarrhea, rash, or fever.
Annie Jacobs:The patient's only prescribed medication is losartan, though he admits that he is been out of this medication for over a month and has not been taking it.
Annie Jacobs:He lives at home with his wife.
Annie Jacobs:He has two adult sons, both of whom live in the area.
Annie Jacobs:He's originally from Honduras and moved to this country four years ago to be closer to his family.
Annie Jacobs:He previously worked in construction but has not worked for the last 10.
Annie Jacobs:He denies a history of smoking, drinking, or drug use.
Annie Jacobs:There's no pets in the home.
Annie Jacobs:He denies any sick contacts or historical contacts with people known to have tuberculosis.
Annie Jacobs:Upon presentation to the emergency department, he was tachycardic, normotensive, afebrile.
Annie Jacobs:He was saturating 94% on room air with respiratory rate of 16 to 18.
Annie Jacobs:Physical exam documented in the ED notes a prominent JVD to 13 centimeters, crackles in the bilateral lung fields, irregularly irregular heart rate with no notable murmurs or extra heart sounds, and two plus pitting edema in the lower extremities.
Annie Jacobs:He underwent E K G and was noted to be in new onset atrial fibrillation with rapid ventricular response to the 160s.
Annie Jacobs:Chest X-ray in the emergency department showed pulmonary edema and massive cardiomegaly.
Annie Jacobs:He was started on diltiazem for rate control.
Annie Jacobs:He was admitted and shortly after admission was started on a apixaban for anticoagulation.
Annie Jacobs:While admitted, he undergoes diuresis and on hospital day two, he undergoes an echocardiogram as part of routine workup for new onset AFib.
Annie Jacobs:It shows a large circumferential pericardial effusion.
Annie Jacobs:We can pause here Dr.
Annie Jacobs:Polk and can you talk about your differential in this?
Christopher Polk:Sure.
Christopher Polk:Although before I dive into that, one question would be, were there clues to the presence of his pericardial effusion prior to obtaining that echo?
Christopher Polk:You know, sometimes hindsight is really 220-200, and many times it's not completely obvious.
Christopher Polk:But I do wonder for this patient, on exam were their distant heart sounds.
Christopher Polk:Did he have low voltage onto E K G?
Christopher Polk:And we are given a chest x-ray that's described as cardiomegaly.
Christopher Polk:And you know, classically for a pericardial effusion or what is described is a water bottle sign of an enlarged cardiac silhouette.
Christopher Polk:And so I just wonder about that appearance of cardiomegaly on the chest x-ray and whether there were just some of those subtle clues to the presence of the effusion be before we got the echo.
Christopher Polk:But since we're talking about differential, the next question really would be, Were there any signs or symptoms of an acute inflammatory syndrome or acute pericarditis, and we're really not given any here.
Christopher Polk:So in the H P I, you talked about there really wasn't fever or chest pain or ST elevations on the EKG, suggestive of pericarditis.
Christopher Polk:He does have a cough, but it sounds like it might just be more from his pulmonary edema.
Christopher Polk:If he did have some of these acute inflammatory symptoms, then I might be more concerned for an infectious etiology, particularly for a pathogenic bacterial infection like Staph aureus, pneumococcus, or other streptococci diseases.
Christopher Polk:NNeisseria, Legionella, Mycoplasma.
Christopher Polk:In my experience, patients with those typical bacterial pathogens generally are fairly ill appearing and, and come in sick with if they have acute pericarditis.
Christopher Polk:In the absence of that, might think about viral pathogens, coxsackievirus, adenovirus, the one we see in adults is usually H I V, uh, which is something to think about.
Christopher Polk:Fungal pathogens might be on our differential, especially the endemic fungi.
Christopher Polk:Blastomycosis, Cocci(dioides), histoplasma.
Christopher Polk:And then of course we can't forget about tb, tuberculosis, and it's really possible for, uh, effusions from TB to really be more indolent with fewer acute inflammatory symptoms, although maybe patients might have weight loss or night sweats.
Christopher Polk:So thinking through some of the infectious etiologies of a pericardial effusion, I would think through that set of possibilities.
Christopher Polk:And then I would also think about non-infectious etiologies, especially given his lack of acute inflammatory symptoms.
Christopher Polk:You know, as ID clinicians, we are often asked to kind of act as a master diagnostician and really consider non-infectious etiologies, and I just often find it particularly satisfying to make a non-infectious diagnosis.
Christopher Polk:But just sort of thinking through those possibilities here.
Christopher Polk:You know, what might they be?
Christopher Polk:Well, he was recently initiated on anticoagulation, so I think we have to think about bleed a little bit, although on this echo he had, there's really no mention of an aortic dissection or leakage into the pericardial sac.
Christopher Polk:You know, always think about MI, which might have a complication of pericardial effusion at some point, although presumably maybe he had some cardiac enzymes done or was assessed for that given his new onset atrial fibrillation.
Christopher Polk:You know, we think about uremia in our adult patients as in etiology in this.
Christopher Polk:Then for this patient, he does have a history of malignancy and malignant effusions might be a consideration.
Christopher Polk:Although usually malignant effusions would complicate lung or breast cancer, leukemia, lymphoma, probably not as an isolated recurrence of prior gastric cancer.
Christopher Polk:That would seem to be unusual, but just sort of thinking through that, uh, mixed edema might cause a pericardial effusion, although, if anything with,
Christopher Polk:new onset atrial fibrillation with rapid ventricular rate.
Christopher Polk:You might think he's hyperthyroid.
Christopher Polk:And then always think about connective tissue disorders too in our differential, right?
Christopher Polk:Lupus, rheumatoid arthritis, granulomatosis with polyangiitis.
Christopher Polk:Sarcoid, maybe even familiar Mediterranean fever, all of which I would think would have systemic manifestations, uh, rather than an isolated effusion, but just sort of thinking through a full differential would consider those.
Christopher Polk:And then that sometimes medications or drugs can cause effusions such as hydralazine, but he really doesn't appear to be on those.
Christopher Polk:So that's a really big differential to both infectious and non-infectious etiologies.
Christopher Polk:But the truth is, a lot of times these effusions are idiopathic and we don't find a good answer
Christopher Polk:and maybe that's the answer here too.
Christopher Polk:So with that differential, Annie, Do you have some more information so that we can maybe narrow it down or focus on where we're going with this case?
Annie Jacobs:Yes, and thank you.
Annie Jacobs:That was very informative.
Annie Jacobs:I do have more information, but I'd actually like to introduce another patient first, if that's okay.
Christopher Polk:Now you're really throwing some curve ball.
Annie Jacobs:This time our patient is in Chogoria, Kenya.
Annie Jacobs:Chogoria is a small town about 140 miles from Nairobi with somewhat limited availability of diagnostics.
Annie Jacobs:Our patient here is a 23 year old man with no known medical history.
Annie Jacobs:He presented to the hospital with shortness of breath of two weeks duration.
Annie Jacobs:He has a slow but progressive onset of his shortness of breath.
Annie Jacobs:At first he noticed it with extended activity, but over the past two to three days, he's been short of breath, even at rest.
Annie Jacobs:He went to another hospital about a week ago and was told that he had pneumonia.
Annie Jacobs:He was prescribed an oral antibiotic.
Annie Jacobs:He isn't sure which one, and he didn't have improvement.
Annie Jacobs:Further history revealed that he's had chest pain and hemoptysis for two weeks leading up to his current presentation.
Annie Jacobs:The chest pain is sharp in nature.
Annie Jacobs:Anterior in location and exacerbated by inspiration and cough.
Annie Jacobs:His cough is productive of white frothy sputum.
Annie Jacobs:He also notes feeling febrile at home with night sweats.
Annie Jacobs:Over the past two weeks though, he is been unable to take his temperature.
Annie Jacobs:He has no other focal symptoms.
Annie Jacobs:His vitals at presentation show sinus tachycardia, 110 to 120 beats per minute with a blood pressure within normal range.
Annie Jacobs:He's febrile to 103.1 Fahrenheit.
Annie Jacobs:He's tachypnic to 24 breaths per minute, but satting well on RA, he's ill appearing in diaphoretic.
Annie Jacobs:Physical exam is significant for the tachycardia and soft heart sounds.
Annie Jacobs:There's no murmurs, rubs, or gallops.
Annie Jacobs:He's using accessory muscles for respiration with subcostal re retractions.
Annie Jacobs:There's no notable rashes and no lower extremity edema.
Annie Jacobs:He has palpable lymphadenopathy.
Annie Jacobs:Mental status was intact.
Annie Jacobs:On the initial assessment.
Annie Jacobs:Labs showed elevated sedimentation rate of 124 millimeters per hour.
Annie Jacobs:His chest x-ray shows blunted costophrenic angles with massive cardiomegaly.
Annie Jacobs:Ekg showed sinus tachycardia with classical electrical alternans.
Annie Jacobs:Point-of-care ultrasound confirms a massive pericardial effusion with RV collapse.
Annie Jacobs:With this initial presentation, what are your initial thoughts, Dr.
Annie Jacobs:Polk?
Annie Jacobs:How is this similar and different than our patient in North Carolina and how does your patient's differential change with this specific history?
Christopher Polk:Yeah, so this patient really had very clear acute onset of inflammatory symptoms.
Christopher Polk:So he sounds sick, ill appearing.
Christopher Polk:He had fevers and chest pain and cough.
Christopher Polk:That's all new and onset.
Christopher Polk:And so I would really lean towards an infectious etiology here much more clearly than in our first patient, again, especially given his acuity.
Christopher Polk:So I would favor a pyogenic bacterial infection, maybe tuberculosis or fungal infection.
Christopher Polk:And of course, given the location, everyone is really thinking TB.
Christopher Polk:But I think we have to stop and really do due diligence and consider the the full infectious differential and think about staphylococcal disease, pneumococcal disease, meningococcal disease, all of which are certainly quite possible here.
Christopher Polk:Of note, where Chogoria is in Kenya is not in the meningitis belt.
Christopher Polk:It's a little south of that, but you know, certainly would remain a consideration.
Christopher Polk:Uh, histoplasma also can occur in Africa, so might consider that as well.
Christopher Polk:I also wanna comment briefly on this patient having cardiac tamponade, which I think is interesting and we didn't really discuss so much in the first case,
Christopher Polk:still was reported to have a large effusion, but is obviously a very important diagnosis to make and assess for.
Christopher Polk:And you know, in tamponade, maybe more related to the rapidity of fluid accumulation than the size, and maybe we suspected when there's J V D in the presence of hypotension, which the second patient really didn't have described interestingly, we might also suspect that if there's electrical alternans on the ekg, but if you don't have a handy point of care ultrasound to look for tamponade, the other quick bedside test you can do is a pulses paradoxus so here you check the patient's blood pressure doing inspiration and expiration and
Christopher Polk:systolic blood pressure drops at least 10 millimeters of mercury.
Christopher Polk:That's a concern and, and I will just briefly comment, the only time I was ever reprimanded as a resident is when I didn't do this, when admitting a patient and the program director came in the next morning and the patient was in tamponade.
Christopher Polk:So it's a quick, easy bedside test you can do that.
Christopher Polk:I'll certainly never forget if you don't have that point of care ultrasound.
Christopher Polk:Um, so are, are we going to find out more about either of these patients, Annie?
Annie Jacobs:Yeah, we can do that.
Annie Jacobs:Let's go back to the United States.
Annie Jacobs:You'll recall our patient is a 70 year old with a history of gastric cancer who came in with shortness of breath and was found to be a new onset AFib.
Annie Jacobs:And on echo, he was noted to have a massive pericardial effusion.
Annie Jacobs:This patient was initially hemodynamically stable.
Annie Jacobs:Recall that we talked about the differential, including malignancy, infection, and hemorrhagic sources of this effusion.
Annie Jacobs:I'll add some basic labs at this point.
Annie Jacobs:His C B C showed a white count of 12,000 with a hemoglobin of 10 and platelets of 400.
Annie Jacobs:His electrolytes were all within normal limits, a Cr of one and normal BUN.
Annie Jacobs:His a s t and a l t were unremarkabe.
Annie Jacobs:He did undergo a CT chest in the emergency department.
Annie Jacobs:The circumferential effusion is again noted, and he had no lesions in the lung parenchyma, cavitary, or otherwise.
Annie Jacobs:He had trace plural, effusions, far too small to consider tapping.
Annie Jacobs:It was actually at this point in the hospital course that infectious diseases was consulted.
Annie Jacobs:As the ID consultant, what would you suggest in terms of diagnostics in this patient at this point in his hospital?
Christopher Polk:Well, you know, as an ID consultant, the first thing we do is go to bedside and take a better history, right?
Christopher Polk:We really try and tease out all of those crazy details that no one else probably cares much about.
Christopher Polk:So, you know, thinking back through this, these pa, this patient, some of the other questions I might ask would be related to further history of any TB exposures.
Christopher Polk:We told, we were told he really didn't have any, but was from, uh, central America.
Christopher Polk:Were there any experiences with incarceration or homelessness or other risk factors we can tease out?
Christopher Polk:Uh, we might think about that in the context of risk factors for endemic fungi as well of.
Christopher Polk:He was here in Charlotte, where we have a little bit of Histoplasma from time to time, but he was from Central America where there's sort of increasing rates of histoplasma.
Christopher Polk:So we might think about that.
Christopher Polk:We might ask about family history of rheumatologic illness, which might.
Christopher Polk:Provide some clues and, and then we would really wanna embark on a further workup.
Christopher Polk:We really have some basic labs here, which is great.
Christopher Polk:He probably doesn't have a uremic effusion.
Christopher Polk:We know that now.
Christopher Polk:But what about an H I V test?
Annie Jacobs:It was negative.
Christopher Polk:Okay.
Christopher Polk:And rheumatologic serologies, presumably those might be.
Annie Jacobs:Yep.
Annie Jacobs:They were all sent by the admitting team and they are in lab being processed.
Christopher Polk:Of course.
Christopher Polk:Um, we do have a CT chest.
Christopher Polk:You gave us some imaging and it doesn't seem to suggest any malignancy or recurrence of malignancy, which I think is, uh, helpful here.
Christopher Polk:You would think there would be some other abnormality in the chest.
Christopher Polk:Uh, to suggest that as there isn't about a third of the cases of pericardial effusion from TB or from malignancy, sorry.
Christopher Polk:I presume maybe he had blood cultures at some point since we were talking about bacterial pathogens.
Annie Jacobs:Yeah, they were collected in the emergency department, no growth after 24 hours.
Christopher Polk:Okay.
Christopher Polk:And, and then the other question is, do we send testing for TB or latent tb, such as an interferon gamma release assay.
Christopher Polk:Right, so an IGRA doesn't diagnose active tb and there's always this question about what do you do if it is it's positive or negative, particularly with patients from a highly endemic area, but it certainly might raise your suspicion if it was, uh, positive.
Christopher Polk:I'm not sure it would completely exclude the diagnosis if it was negative.
Christopher Polk:You know, just looking at some case series from tuberculous peritonitis, a positive igra has a sensitivity and specificity of around 85%.
Christopher Polk:So that's a positive predictive value, about 90% negative predictive value, 70%.
Christopher Polk:So it might raise your suspicion for tuberculosis, um, if it's positive, but again, Really excluded from the diagnosis, either if it's negative.
Christopher Polk:Other things we might do really boil down to obtaining fluid or tissue for diagnosis here.
Christopher Polk:Right?
Christopher Polk:And pericardial fluid, while helpful is only diagnostic and about 40% of the time pericardial effusion with from tb.
Christopher Polk:So something to keep in mind and we can't really use lights criteria on pericardial fluid the way we can for pleural effusions.
Christopher Polk:That's part is not helpful.
Christopher Polk:But what we can send, obviously our AFB smears and cultures, and then an adenosine deaminase test.
Christopher Polk:Which maybe is worth talking a little bit about.
Christopher Polk:In addition to TB pcr, adenosine deaminase is part of purine metabolism that is elevated in TB and given off by lymphocytes.
Christopher Polk:It's not exclusive to tuberculosis, but is helpful
Christopher Polk:to make a diagnosis of a ppleurall or pericardial effusion from tb.
Christopher Polk:So I think it might be really helpful here to send that.
Christopher Polk:The other gold standard we can think about is doing a pericardial biopsy, and we classically think about this as increasing yield for making a diagnosis of TB from in the pericardial space.
Christopher Polk:Unfortunately, it's maybe a little less sensitive than we like to think of it as.
Christopher Polk:So an AFB smear from pericardial fluid, fluid is only about 5% sensitive, culture is about 50%, and a pericardial biopsy does increase your sensitivity, but only to about 65%.
Christopher Polk:So making the diagnosis here is a little bit of a challenge no matter what modality you use, but you probably do wanna obtain some fluid and try and think through sending some of those tests again, particularly the adenosine deaminase or the TB pcr, which may have a sensitivity of up to 90%.
Christopher Polk:And then finally, you could also think you about sending a T-SPOT from your fluid, which also is pretty sensitive, but about 90%.
Christopher Polk:So that's some of the things I would sort of think through in workup of the patient from the us What, what about that patient in Kenya?
Annie Jacobs:Yeah, well, I will pass those recommendations onto the primary team.
Annie Jacobs:But going back to our patient in Kenya, with that massive pericardial effusion, our patient has become hypotensive to seventies over fifties, in tachycardic to the 130s.
Annie Jacobs:He's also become increasingly somnolent.
Annie Jacobs:He's definitely not stable.
Annie Jacobs:The patient undergoes an emergent bedside pericardiocentesis with placement of a temporary dialysis catheter to serve as a drain.
Annie Jacobs:One liter of dark bloody fluid was drained in the first 30 minutes after placement.
Annie Jacobs:The patient's hemodynamics improved.
Annie Jacobs:Soon thereafter, the patient was started on empiric RIPE therapy.
Annie Jacobs:Over the next three days, a total of three and a half liters of fluid was drained from the pericardial drain throughout the hospital course, the patient clinically improved with a complete resolution of that altered mental status.
Annie Jacobs:Gene expert testing of the pericardial fluid did confirm a diagnosis of tuberculosis.
Annie Jacobs:Dr.
Annie Jacobs:Polk, what are your thoughts about this?
Christopher Polk:Yeah.
Christopher Polk:No one's surprised here, right?
Christopher Polk:That that's what everyone was kind of thinking a little bit, especially given the location.
Christopher Polk:That being said, I would go back to, don't jump to conclusions, do the workup.
Christopher Polk:I, I'd also say that this is a great demonstration of how epidemiology matters, right?
Christopher Polk:So in case series of pleural effusions from the US and Europe, Then most are either idiopathic or from malignancy with really the minority being from infection.
Christopher Polk:Alternatively, from South Africa, a case series published on pericardial effusions identified TB as the most common cause.
Christopher Polk:So epidemiology always matters.
Annie Jacobs:Absolutely.
Annie Jacobs:That was a really satisfying textbook case from Kenya.
Annie Jacobs:But let's jump back to the US.
Annie Jacobs:With our 70 year old, with our pericardial effusion of unknown etiology, the patient did undergo a pericardiocentesis with one liter of bloody fluid removed cultures and a f B were sent.
Annie Jacobs:Notably that TB P C R that you recommended was not sent in this patient.
Annie Jacobs:No organisms were seen on the initial gram stain.
Annie Jacobs:What treatments, if any, are you starting on this patient at this point in the hospital course and at what point did we consider empiric tuberculosis therapy in this patient in the United States?
Christopher Polk:Well, this is interesting because now we're given information that this was really a large hemorrhagic effusion, and when we think through our differential as far as the etiologies, Of pericardial effusions.
Christopher Polk:There are only a few things that probably give you a large hemorrhagic effusion most likely, and those are bleed, malignancy and tb.
Christopher Polk:And we already kind of excluded bleed.
Christopher Polk:And the fact that he really didn't have trauma here or mention of dissection or concern on echo.
Christopher Polk:So we're down to thinking about cancer or tb and we've already talked about how it would be unusual for gastric cancer to recur just in the pericardium and from the chest imaging we have.
Christopher Polk:We don't see a suggestion of other chest cavity malignancy that might go with a malignant effusion.
Christopher Polk:So we're down to thinking about tuberculosis again, and the fact that he did have a prior residence in a country with higher endemicity of tb.
Christopher Polk:I'd also say we previously talked about sending an interferon gamma release assay here, and I'm guessing that's still not back yet.
Annie Jacobs:Still in lab
Christopher Polk:and, and that ADA is still in lab?
Annie Jacobs:Yep, still in lab.
Christopher Polk:But hopefully it was at least sent unlike the TB PCR.
Christopher Polk:You know, at my institution, those usually come back within a week or so, and he's relatively clinically stable.
Christopher Polk:So to your question, as far as empiric therapy, I'm not sure there's a huge rush.
Christopher Polk:That being said, if he were sick, certainly would consider starting therapy for a TB and regardless, given where it is on our differential, I presume he's in airborne isolation and we're trying to get three sputums for a f b smear at this
Christopher Polk:point.
Christopher Polk:Yes, we are working on it.
Christopher Polk:Mm-hmm.
Annie Jacobs:So our patient did undergo some workup that you asked for earlier in this conversation.
Annie Jacobs:His rheumatologic workup came back with a negative a n a rheumatoid factor in c c p, and complements were within normal.
Annie Jacobs:For oncologic workup, he underwent a total body PET scan without hypermetabolic activity anywhere in his body.
Annie Jacobs:His infectious workup was a covid and respiratory pathogen panel that came back negative.
Annie Jacobs:The H I V that we already mentioned came back negative.
Annie Jacobs:He had a negative A f B sputum smears.
Annie Jacobs:Three were collected, specifically negative blood cultures, but his QuantiFERON did return.
Annie Jacobs:The pleural fluid was sent for analysis and the ADA was elevated at 55 milliliters.
Annie Jacobs:What do we make of diagnosis at this point?
Christopher Polk:So we're back to tuberculosis just in a different location, and of course we're gonna start him on therapy at this point with what we term is ripe.
Christopher Polk:Rifampin, isoniazid, pyrazinamide, ethambutol with a little pyridoxine thrown in for.
Christopher Polk:Prevention of toxicity and you know, certainly want to still get those smears.
Christopher Polk:He'll, he'll need referral to the health department and ongoing treatment.
Christopher Polk:But just thinking about TB pericardial disease in general, since we have these two cases, it's interesting because it's really rare.
Christopher Polk:It's less than 5% of cases of TB present this way and unfortunately, Classically, it had a fairly high mortality rate prior to sort of modern, effective therapy, and still we worry about the complication of constrictive pericarditis because in the later stages of pericardial.
Christopher Polk:Uh, TB disease, the fluid gets reabsorbed, and then there's scarring of the pericardium, granuloma formation, and constrictive heart physiology can occur.
Christopher Polk:So that's a concern.
Christopher Polk:Certainly treatment, uh, with ripe is indicated there.
Christopher Polk:And then sometimes steroids have been given and the, this is maybe a little controversial, and the, the data.
Christopher Polk:Inconclusive, but they might be helpful early.
Christopher Polk:Although studies really haven't completely demonstrated definitive benefit in preventing constrictive pericarditis, but it is a concern.
Christopher Polk:And if there's progression in some patient, they may need surgical pericardiectomy for constructive pericarditis, but two really interesting cases in different locales
Christopher Polk:leading to the same diagnosis.
Sara Dong:Thank you so much to Annie and Christopher for making this awesome episode spanning two cases across two continents.
Sara Dong:Don't forget to check out the website febrilepodcast.com to find the consult notes, which are written complements to the show, with links to references, our library of ID infographics, and a link to our merch store.
Sara Dong:Please reach out if you have any questions, suggestions for future shows, or wanna be more involved with Fbri.
Sara Dong:Thanks for listening.
Sara Dong:Stay safe and I'll see you
