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Chest Infections |

A 40-Year-Old Woman With Postpartum Cardiac Tamponade

Avinash Ramdass, MD; James Cury, MD; Tauseef Qureshi, MD; Jasdip Matharu, MD; Vandana Seeram, MD
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University of Florida College of Medicine, Jacksonville, FL


Chest. 2013;144(4_MeetingAbstracts):239A. doi:10.1378/chest.1698992
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Abstract

SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Mycobacterial Tuberculous (MTB) pericarditis remains an uncommon etiology for severe pericardial effusion and manifestation as cardiac tamponade is rare [1,2].

CASE PRESENTATION: A 40 year old HIV negative woman was admitted in active labor at 38 weeks gestation. On her first postpartum day she complained of mild progressive central chest pain, dyspnea and was febrile at 103.5 degrees Fahrenheit. On her third postpartum day, she became hypotensive, tachycardic and tachypneic. Examination findings included an elevated jugular venous pulsation, muffled heart sounds and crackles on lung exam. An erect chest roentgenogram revealed a globular heart and bilateral pleural effusions. An echocardiogram confirmed the presence of a large pericardial effusion with cardiac tamponade (Figure 1). Pericardiocentesis was performed with the removal of 850 ml of serosanguinous fluid which restored hemodynamic stability. Pericardial fluid analysis by Light’s criteria was remarkable for an exudative process. Cytological evaluation revealed a reactive non-neoplastic process. Adenosine deaminase levels were elevated, polymerase chain reaction (PCR) and culture were positive for MTB complex. Acid fast stain demonstrated mycobacterial organisms (Figure 2).

DISCUSSION: Pericardial involvement from TB usually develops by retrograde lymphatic spread of mycobacteria from mediastinal lymph nodes or by hematogenous spread from the site of primary infection [2]. A delayed hypersensitivity reaction to the protein antigens of viable acid-fast bacilli penetrating the pericardium is responsible for the formation of tuberculous pericarditis and is largely mediated by TH-1 lymphocytes [2]. Light’s criteria for an exudative pleural effusion are likely to have the same clinical significance in pericardial effusions [2]. The diagnosis of isolated MTB pericarditis must be confirmed by a positive smear, culture, or PCR of a pericardial fluid or biopsy sample [2]. Pericardial fluid AFB smear is variably positive from 0-42% in people with MTB pericardial effusions [2]. Pericardial biopsy MTB PCR has a higher yield compared to pericardial fluid culture with sensitivities of 80% and 75% respectively [2]. Pregnancy suppresses the Th1 pro-inflammatory response which may mask symptoms while increasing susceptibility to new infection or reactivation [2]. After delivery, Th1 suppression reverses and symptoms are exacerbated similar to other immune reconstitution syndromes [3].

CONCLUSIONS: Effusive pericardial TB resulting in cardiac tamponade is rare and can be exacerbated by postpartum immune reconstitution syndrome.

Reference #1: Gladych E, Goland S, Attali M, et al. Cardiac tamponade as a manifestation of tuberculosis. South Med J. 2001;94(5):525-8.

Reference #2: Mayosi BM, Burgess LJ, Doubell AF. Tuberculous Pericarditis. Circulation. 2005; 112(23): 3608-3616.

Reference #3: Singh N and Perfect JR. Immune reconstitution syndrome and exacerbation of infections after pregnancy. Clin Infect Dis 2007; 45(9): 1192-1199.

DISCLOSURE: The following authors have nothing to disclose: Avinash Ramdass, James Cury, Tauseef Qureshi, Jasdip Matharu, Vandana Seeram

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