Case 22-2004: A 30-Year-Old Woman with a Pericardial Effusion
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《新英格兰医药杂志》
To the Editor: In the Case Records article about the care of a young woman with pleural and pericardial effusions, pulmonary nodules, and mediastinal lymphadenopathy, described by Nardell et al. (July 15 issue),1 the eventual diagnosis was found to be tuberculosis, and the clinicians correctly prescribed antituberculous treatment. We would like to comment on two issues that are not discussed in the article but that should be considered in the management of tuberculosis involving the pericardium.
Treatment with adjuvant corticosteroids has been associated with clinical benefit in constrictive2 and effusive3 tuberculous pericarditis, with specific improvements in functional status, mortality, and the need for repeated pericardiocentesis. These results have led some authors to recommend corticosteroid treatment for tuberculous pericarditis before the development of irreversible constriction and in conjunction with antituberculous therapy. A recently updated meta-analysis4 acknowledges the potential for a clinical benefit but concedes that larger trials are needed to confirm the size of the effect, especially in patients infected with the human immunodeficiency virus.
Finally, the importance of early initiation of empirical antituberculous treatment should be emphasized for all potentially life-threatening forms of tuberculosis, including tuberculous pericarditis.5
Victoria J. Cook, M.D.
British Columbia Centre for Disease Control
Vancouver, BC V5Z 4R4, Canada
victoria.cook@bccdc.ca
J. Mark FitzGerald, M.D.
Centre for Clinical Epidemiology and Evaluation
Vancouver, BC V5Z 1L8, Canada
References
Case Records of the Massachusetts General Hospital (Case 22-2004). N Engl J Med 2004;351:279-287.
Strang JIG, Kakaza HHS, Gibson DG, Girling DJ, Nunn AJ, Fox W. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet 1987;2:1418-1422.
Strang JI, Kakaza HH, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet 1988;2:759-764.
Mayosi BM, Ntsekhe M, Volmink JA, Commerford PJ. Interventions for treating tuberculous pericarditis. Cochrane Database Syst Rev 2002;4:CD000526-CD000526.
FitzGerald JM, Menzies D. Missed TB: commentary. Rockville, Md.: Agency for Healthcare Research and Quality, April 2004. (Accessed October 1, 2004, at http://webmm.ahrq.gov/cases.aspx?ic=56.)
Dr. Nardell replies: Drs. Cook and FitzGerald point out the importance of corticosteroids in the management of tuberculous pericarditis. They will be relieved to know that in my discussion of this case at the clinicopathological conference, I cited the same study showing a reduction in mortality from 11 percent to 3 percent.1 I also commented on the more controversial use of corticosteroids in the prevention or treatment of constrictive pericarditis, once the acute inflammatory phase has resolved. As noted by Strang et al., even with appropriate antibiotic and corticosteroid therapy, as many as a third of patients may require pericardiectomy to restore cardiac function, with a favorable outcome in most cases.2 Space constraints limited both the diagnostic and the therapeutic portions of the discussion. Drs. Cook and FitzGerald have appropriately focused attention on this important therapeutic intervention, as well as on the importance of empirical treatment of tuberculosis in cases of pericarditis where exposure to tuberculosis is possible, such as in health care workers and persons who travel to areas where tuberculosis is endemic — both of which were true in this case.
Edward A. Nardell, M.D.
Harvard Medical School
Boston, MA 02115
References
Strang JIG, Kakaza HHS, Gibson DG, Girling DJ, Nunn AJ, Fox W. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet 1987;2:1418-1422.
Strang JI, Kakaza HH, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet 1988;2:759-764.
Treatment with adjuvant corticosteroids has been associated with clinical benefit in constrictive2 and effusive3 tuberculous pericarditis, with specific improvements in functional status, mortality, and the need for repeated pericardiocentesis. These results have led some authors to recommend corticosteroid treatment for tuberculous pericarditis before the development of irreversible constriction and in conjunction with antituberculous therapy. A recently updated meta-analysis4 acknowledges the potential for a clinical benefit but concedes that larger trials are needed to confirm the size of the effect, especially in patients infected with the human immunodeficiency virus.
Finally, the importance of early initiation of empirical antituberculous treatment should be emphasized for all potentially life-threatening forms of tuberculosis, including tuberculous pericarditis.5
Victoria J. Cook, M.D.
British Columbia Centre for Disease Control
Vancouver, BC V5Z 4R4, Canada
victoria.cook@bccdc.ca
J. Mark FitzGerald, M.D.
Centre for Clinical Epidemiology and Evaluation
Vancouver, BC V5Z 1L8, Canada
References
Case Records of the Massachusetts General Hospital (Case 22-2004). N Engl J Med 2004;351:279-287.
Strang JIG, Kakaza HHS, Gibson DG, Girling DJ, Nunn AJ, Fox W. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet 1987;2:1418-1422.
Strang JI, Kakaza HH, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet 1988;2:759-764.
Mayosi BM, Ntsekhe M, Volmink JA, Commerford PJ. Interventions for treating tuberculous pericarditis. Cochrane Database Syst Rev 2002;4:CD000526-CD000526.
FitzGerald JM, Menzies D. Missed TB: commentary. Rockville, Md.: Agency for Healthcare Research and Quality, April 2004. (Accessed October 1, 2004, at http://webmm.ahrq.gov/cases.aspx?ic=56.)
Dr. Nardell replies: Drs. Cook and FitzGerald point out the importance of corticosteroids in the management of tuberculous pericarditis. They will be relieved to know that in my discussion of this case at the clinicopathological conference, I cited the same study showing a reduction in mortality from 11 percent to 3 percent.1 I also commented on the more controversial use of corticosteroids in the prevention or treatment of constrictive pericarditis, once the acute inflammatory phase has resolved. As noted by Strang et al., even with appropriate antibiotic and corticosteroid therapy, as many as a third of patients may require pericardiectomy to restore cardiac function, with a favorable outcome in most cases.2 Space constraints limited both the diagnostic and the therapeutic portions of the discussion. Drs. Cook and FitzGerald have appropriately focused attention on this important therapeutic intervention, as well as on the importance of empirical treatment of tuberculosis in cases of pericarditis where exposure to tuberculosis is possible, such as in health care workers and persons who travel to areas where tuberculosis is endemic — both of which were true in this case.
Edward A. Nardell, M.D.
Harvard Medical School
Boston, MA 02115
References
Strang JIG, Kakaza HHS, Gibson DG, Girling DJ, Nunn AJ, Fox W. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet 1987;2:1418-1422.
Strang JI, Kakaza HH, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet 1988;2:759-764.