Tuberculous pericarditis presenting as multiple free floating masses in pericardial effusion

Abstract

Pericarditis is a rare manifestation of tuberculosis (Tb) in children. A 14-yr-old Korean boy presented with cardiac tamponade during treatment of pulmonary tuberculosis. He developed worsening anemia and persistent fever in spite of anti-tuberculosis medications. Echocardiography found free floating multiple discoid masses in the pericardial effusion. The masses and exudates were removed by pericardiostomy. The masses were composed of pink, amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes with numerous acid-fast bacilli, which were confirmed as Mycobacterium species by polymerase chain reaction. The persistent fever and anemia were controlled after pericardiostomy. This is the report of a unique manifestation of Tb pericarditis as free floating masses in the effusion with impending tamponade.

Keywords: Cardiac Tamponade; Pericardial Effusion; Pericarditis; Tuberculosis.

Fig. 1

Radiologic findings of the chest. (A) Haziness in right upper and middle lung was noted. (B) Consolidation, micronodules, and branching structures were found in the right lung, and lymph node enlargements were noted in both hilum. (C) Aggravated haziness in the right lung and newly appeared consolidation in the right lower lung were found on 7th hospital day.

Fig. 2

Hemoglobin (Hb) was decreased gradually since admission till the 9th hospital day (HD), when pericardiostomy was performed. C-reactive protein (CRP) increased initially and then decreased. After pericardiostomy, hemoglobin increased till discharge and CRP also decreased to normal at discharge.

Fig. 3

Echocardiographic findings. (A) Free floating multiple round discoid echogenic masses in the large amount of pericardial effusion, the thickened pericardium and shaggy echo-dense appearance surrounding the epicardium in subcostal view, and (B) marked variation in mitral inflow Doppler pattern.

Fig. 4

Gross specimens obtained from pericardial space.

Fig. 5

Microscopic finding. (A) A pink, amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes (H&E stain, × 400). (B) Numerous acid-fast bacilli (Ziehl-Neelsen stain, × 1,000).