Tuberculous Pericarditis with tamponade in COVID-19: A case report

doi:10.21203/rs.3.rs-45055/v1

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Case Report

Tuberculous Pericarditis with tamponade in COVID-19: A case report

https://doi.org/10.21203/rs.3.rs-45055/v1

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Introduction

Tuberculous pericarditis is a rare manifestation of tuberculosis infection. COVID-19 pandemic poses a challenge in detecting uncommon disease. Pericardial effusion with tamponade has been described with COVID-19 but the association with tuberculosis is not yet known.

Case presentation

A 47-year-old man was admitted with symptoms of COVID-19 infection. Rapid progression of cardiomegaly on radiograph with clinical deterioration were suggestive of pericardial tamponade. Urgent pericardiocentesis revealed hemoserous fluid, elevated adenosine deaminase and positive TB PCR. He was started on steroid, anti-tuberculous therapy and Remdesivir with marked improvement of symptoms. Repeat echocardiogram and CT Thorax showed resolution of pericardial fluid and patient was discharged well.

Conclusions

This case highlights the difficulty in detecting a concomitant rare but important disease. The development of massive pericardial tamponade acutely is not pathognomonic for COVID-19, and a careful diagnostic process involving multi-modality imaging, occurred to arrive at a diagnosis of tuberculosis.

Infectious Diseases

Tuberculosis

Pericarditis

Pericardial tamponade

COVID-19

Case report

Tuberculous pericarditis is rare and associated with significant morbidity and mortality.1 In the midst of COVID-19 pandemic, early detection of concomitant infection is important. We present the case of a patient admitted with symptoms of COVID-19 infection that developed pericardial tamponade subsequently. Urgent pericardiocentesis revealed evidence of tuberculous pericarditis and he was appropriately managed.

A 47-year-old gentleman presented with productive cough, pleuritic chest pain and fever for two days. Physical examination revealed a febrile, generally ill appearing gentleman. He had a regular pulse, S1/S2 were normal without murmurs or rub. Lung examinations revealed left basal crepitations. Vital signs were blood pressure 130/83 mmHg, heart rate 104 beats/min, oxygen saturation 97% on room air, respiratory rate 16/min, and temperature 38^oC.

Chest X- ray showed right lower zone paracardiac opacities (Figure 1) and he was transferred to the isolation ward. SARS-CoV-2 PCR came back positive from his nasopharyngeal swab. The patient did not have any significant medical history. He denied travel but he was in close contact with a colleague with COVID-19. He came from a TB endemic area.

He deteriorated on day 3 of hospitalization requiring 4L nasal cannula to achieve oxygen saturation of 94%. Electrocardiogram (ECG) showed sinus tachycardia with normal QRS complexes (Figure 2). High sensitive troponin I was 4 ng/ml (normal values: <14 ng/ml). There was absolute monocytosis (0.92 x 109/L) and elevated C-reactive protein (CRP) at 134.7 mg/L (normal values < 5 mg/L). A repeat chest X-ray showed marked increased in heart size (Figure 3). He was started on remdesivir.

Subsequent ECG revealed persistent sinus tachycardia and no evolution of ST-T wave changes. Labs were remarkable for monocytosis (1.02 x 109/L). Liver function tests and coagulation panel were normal. Arterial blood gas showed acute respiratory alkalosis with pH 7.48, pCO2 39, pO2 68, Bicarbonate of 29 on 3L nasal cannula. Lactate was raised at 2.7 mmol/L (normal value < 2 mmol/L). Transthoracic echocardiogram demonstrated hyperdynamic left ventricle with LVEF of 65%. There was right atrial collapse, diastolic collapse of right ventricle, 3.5 cm of pericardial effusion and plethoric inferior vena cava (Video 1,2). The effusion was noted to be complex with fibrin deposits adhering to the myocardium (Video 3).

The patient was transferred to the intensive care unit. The patient developed sinus tachycardia (range up to 130 beats per minute) with concomitant febrile episodes of 39^oC. Pericardiocentesis was performed in view of persistent tachycardia and rapid accumulation of pericardial effusion. The procedure was done under echocardiographic guidance.

Pericardiocentesis yielded 900 mL of hemoserous fluid [fluid lactate dehydrogenase (LDH) 2,253 IU/L, fluid/serum LDH > 0.6]. Cytology was negative for malignancy. Adenovirus PCR, Enterovirus PCR and SARS-CoV-2 PCR were negative. Acid fast bacilli was detected and TB PCR was positive. Fluid microscopy revealed predominantly nucleated cells (8,513 cells/uL) with 91% lymphocytes. Adenosine deaminase for pericardial fluid was significantly elevated at 44U/L (normal value < 20U/L). Retroviral screen was negative. The immediate resolution of tachycardia (heart rate reduced to 80-90 beats per minute) signifies the hemodynamic improvement gained from relieving the tamponade. The pericardial effusion was highly diagnostic of tuberculous pericarditis in the absence of coagulopathy, malignancy and autoimmune etiologies. He was commenced on rifampicin, isoniazid, ethambutol and pyrazinamide. Subsequent echocardiogram showed resolution of effusion with marked improvement of symptoms. A follow up CT Thorax revealed left lung lower lobe collapse- consolidation, small pleural effusion with marked reduction in pericardial effusion (Figure 4).

Ever since the first cases of pneumonia of unknown origin were described in Wuhan, China in January 2020, COVID-19 has rapidly spread worldwide resulting in a public health emergency. Fever, myalgia, and respiratory symptoms such as dry cough and dyspnea are common presentations. Complications described in the Intensive Care Unit (ICU) include shock, Acute Respiratory Distress Syndrome (ARDS), arrhythmias and acute cardiac injury.²Case reports of cardiac involvement including Acute ST-Elevation Myocardial infarction, myocarditis, stress cardiomyopathy and arrhythmias have also been reported.^3-5

We describe a case of a patient presenting to the hospital with COVID-19 infection and subsequently developing a pericardial effusion with cardiac tamponade.

While viral infections such as Epstein-Barr virus, Parvovirus B19 and Coxsackievirus are known to cause pericarditis and pericardial effusion, little is known about the pericardial complications of COVID-19 and their pathophysiology.⁶ The fibrinoid appearance of pericardial effusion has been strongly associated with pericardial inflammation, as in the case of tuberculoid, bacterial or malignant pericardial effusion.^7,8 This could also be postulated to be due to increased viral expression in the heart via angiotensin-converting enzyme 2 (ACE2) as the entry receptor, resulting in an inflammatory response, although more studies are required to substantiate this. ⁹ We described a case, to our knowledge, the first case of tuberculous pericarditis with tamponade in COVID-19 infection. The appearance of fibrin, lymphocyte rich, elevated adenosine deaminase level with detection of acid fast bacilli and positive TB PCR in the pericardial fluid is pathognomonic of tuberculous involvement. ^10,11 There is a possibility that COVID-19 infection induced an inflammatory response that serves as a nidus for TB reactivation in this patient. In addition, this may explain the rapid progression of pericardial tamponade as TB normally runs an indolent course. TB pericarditis is closely linked to constrictive pericarditis with significant morbidity and mortality.¹ Treatment with steroids may shorten the time to resolution of symptoms, such as tachycardia and restriction of activity. However, this was not shown to reduce mortality or retard the progression to irreversible constrictive pericarditis.¹²

To date, there is an increasing number of case reports describing cardiac involvement with COVID-19 infection. Certain cardiac manifestations such as myocarditis and pericardial effusion can be missed without awareness and heightened clinical suspicion. Case series from Italy reported 20 patients with active TB who developed COVID-19 infection subsequently, but none was associated with pericarditis or tamponade. ¹³

In conclusion, TB pericarditis is a rare manifestation of rapid development of massive pericardial effusion. The presence of TB pericarditis, and consequently its risk, may not be easily identified in the face of COVID-19 pandemic. Thus, a low threshold to use serial echocardiography and dedicated imaging modalities, including CT may be appropriate, particularly in young patient who deteriorate at an alarming speed. Noteworthy, to the best of our knowledge, the current case comprises the first case of concurrent tuberculous pericarditis with tamponade in COVID-19.

COVID-19: 2019 novel coronavirus

CT: Computed Tomography

ECG: Electrocardiogram

LDH: Lactate dehydrogenase

LVEF: Left ventricular ejection fraction

PCR: Polymerase chain reaction

SARS-CoV-2: Severe acute respiratory syndrome coronavirus type 2

TB: Tuberculosis

TTE: Transthoracic echocardiogram

Ethics approval and consent to participate

Not applicable.

Consent to publish

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor- in-Chief of this journal.

Availability of data and materials

The datasets supporting the conclusions of this article are included within the article.

Competing interests

The authors declare that they have no competing interests.

Funding

No source of funding.

Authors’ Contributions

SW: Drafting the manuscript, acquisition of data. KX: drafting the manuscript. YW: supervision and revision of manuscript. All authors read and approved the manuscript.

Acknowledgments

Not applicable.

Moyasi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. 2005;112:3608-3616. http://doi: 0.1161/circulationaha.105.543066.\
Wang DW, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA 2020;323(11),1061-1069.
Minhas AS, Scheel P, Garibaldi B, et al. Takotsubo Syndrome in the Setting of COVID-19 Infection. J Am Coll Cardiol: Case Reports. 2020. doi: 10.1016/j.jaccas.2020.04.023. [Epub ahead of print]
Kir D, Mohan C, Sancassani R. HEART BRAKE-An unusual cardiac manifestation of Coronavirus disease 2019 (COVID-19). J Am Coll Cardiol: Case Reports. 2020. doi: 10.1016/j.jaccas.2020.04.026. [Epub ahead of print]
Inciardi RM, Lupi L, Zaccone G, et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiology. 2020. doi: 10.1001/jamacardio.2020.1096.
Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis. JAMA 2015;314(14),1498-506. http://doi: 1001/jama.2015.12763.
Kim SH, Song JM, Jung IH, et al. Initial echocardiographic characteristics of pericardial effusion determine the pericardial complications. Int J Cardiol 2009;136(2),151–5. http://doi: 1016/j.ijcard.2008.04.033.
Arroyo M, Soberman JE. Adenosine deaminase in the diagnosis of tuberculous pericardial effusion. Am J Med Sci 2008;335(3):227- http://doi: 10.1097/MAJ.0b013e3180cab71a.
Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell, 2020;181(2):271-80. doi: 10.1016/j.cell.2020.02.052.
Castro DJ, Nuevo GD, Perez-Rodriguez E, et al. Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions. Eur Respir J, 2003;21:220-224. doi:10.1183/09031936.03.00051603.
Kelam MA, Ganie FA, Shah BA, et al. The diagnostic efficacy of adenosine deaminase in tubercular effusion. Oman Med J, 2013;28(6):417-421. doi:10.5001/omj.2013.118.
Barbara WT, Rabih, OD. Tuberculous Pericarditis: Optimal diagnosis and Management. Clinical Infectious Diseases, 2001;33(7)954- http://doi: 10.1086/322621.
Stochino C, Villa S, Zucchi P, et al. Clinical characteristics of COVID-19 and active tuberculosis co-infection in an Italian reference hospital. Eur Respir J. Jun 2020(1):2001708. doi:10.1183/13993003.01708-2020. [Epub ahead of print]

Video1.mp4
Parasternal long axis view on echocardiogram showed right ventricular collapse with pericardial effusion.
Video3.mp4
Complex pericardial effusion with multiple fibrin strands adhering to myocardium.
Video2.mp4
Apical 4 chamber on echocardiogram showing large pericardial effusion with right atria and right ventricle collapse. LVEF 65%.

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Tuberculous Pericarditis with tamponade in COVID-19: A case report

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Introduction

Case Presentation

Discussion And Conclusion

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