A 53-year-old malnourished man with no significant past medical history had worked his entire life as a farmer in rural Colombia. He went to a local emergency room because of 2 months of poor appetite, malaise, high spiking fevers, 10 Kg weight loss, and night sweats. He also had progressive exertional dyspnea and anterior chest pain for 2 days. On physical examination he was afebrile, arterial pressure 90/60, and heart rate 100/min. A pulsus paradoxus, jugular vein engorgement, soft heart sounds, and sudden inspiratory splitting of the second heart sound were found. A computed tomographic scan of the thorax showed a large pericardial effusion with pericardium contrast enhancing but no pulmonary opacities (
). A transthoracic echocardiography confirmed pericardial tamponade (
) that led to pericardiocentesis, which yielded 2,200 mL of reddish liquid with 5.9 gm/dL total protein; 2,300 leukocytes/mL (70% Lymphocytes); glucose 2 mg/dL; and an adenosine deaminase level of 234 U/L. Histologic examination of pericardial tissue showed granulomas with multinucleated giant cells (
) and scarce acid-fast bacillae (
); culture of pericardium grew Mycobacterium tuberculosis. A test for human immunodeficiency virus was negative. He was started on four antituberculosis medications plus Prednisone, and discharged 2 weeks after admission. Unfortunately, 2 months later he was readmitted because of constrictive pericarditis, and a pericardiectomy was performed. After 6 months of anti-TB therapy, the patient remained well.
Coronal view of thorax CT showing a large amount of pericardial effusion with pericardium contrast enhancing.
Axial view of thorax CT showing a large amount of pericardial effusion with pericardium contrast enhancing.
Transtoracic echocardiographic image of the heart showing a large pericardial effusion.
Transthoracic echocardiography showing the surface of the heart with a shaggy appearance, with frond-like structures extending to the parietal pericardium.
Histologic examination of pericardial tissue showing granulomas with multinucleated giant cells.
Ziehl-Neelsen stain showing scarce acid-fast bacillae.