tuberculous pericarditis
Introduction
Introduction to tuberculous pericarditis Early tuberculous pericarditis is fibrinous and bloody pericarditis, followed by pericardial effusion, followed by pericardial hypertrophy, which can be converted to subacute or chronic phase, and partially developed into pericardial constriction. Early treatment of tuberculous pericarditis is important for prognosis, and once the diagnosis is clear, anti-tuberculosis treatment or surgical treatment is taken. Tuberculous pericarditis in China occupies an important position in pericardial diseases, accounting for 21.3% to 35.8% of pericardial diseases. Active control of the prevalence of tuberculosis can significantly reduce the incidence of tuberculous pericarditis. Foreign reports of pericarditis are the first in non-specificity, and domestic tuberculosis is the most common. Tuberculous pericarditis in China occupies an important position in pericardial diseases, accounting for 21.3% to 35.8% of pericardial diseases. basic knowledge The proportion of the disease: the incidence of this disease is about 1-2% in patients with tuberculosis Susceptible people: mostly young people, more common in men Mode of infection: non-infectious Complications: Cardiogenic cirrhosis, edema
Cause
Causes of tuberculous pericarditis
(1) Causes of the disease
There are 4 types of Mycobacterium tuberculosis: human, bovine, bird and mouse, while human pathogenic bacteria are human tuberculosis and bovine tuberculosis. Most of the children's tuberculosis in China is caused by human tuberculosis, tubercle bacillus Strong resistance, in addition to acid resistance, alkali resistance, alcohol resistance, cold, heat, dry, light and chemical substances have strong tolerance, damp heat has strong bactericidal power against tuberculosis, At 65 ° C for 30 min, 70 ° C for 10 min, 80 ° C for 5 min to kill, dry heat sterilization is poor, dry heat 100 ° C takes more than 20 minutes to kill, so dry heat sterilization, temperature needs high, time needs to be long, inside The tuberculosis bacteria are killed within 2 hours of direct sunlight, while the ultraviolet light only takes 10 minutes. On the contrary, it can survive for several months in the dark. The tuberculosis bacteria in the sputum use 5% carbolic acid (phenol) or 20% bleaching powder. For liquid disinfection, it takes 24 hours to take effect.
(two) pathogenesis
The occurrence of tuberculous pericarditis often includes intrathoracic lymphatic tuberculosis, pleural or peritoneal tuberculosis, which may be caused by lymphatic reflux or direct spread. It may also be directly ruptured into the pericardial cavity by the liquefaction lymph nodes near the pericardium, or by dissemination of systemic blood. The pathological process of tuberculous pericarditis includes four periods: dryness, exudation, absorption and narrowing, two stages of clinical exudation and narrowing, and exudative pericarditis may be systemic multiple serositis. In part, it reflects the body's high-sensitivity reaction to tuberculosis, and there are many different types of serous fibrous exudate accumulated in the pericardial cavity. There are scattered miliary tuberculosis lesions or cheese-like changes on the surface of the pericardium, and the pericardium is swollen and covered. Cellulose, tarnishing, when the course of the disease is smooth, the pericardium and cellulose can be completely restored to normal after absorption of the exudate and cellulose. For example, the exudate is absorbed and the cellulose is mechanized. The connective tissue hyperplasia causes the pericardium to thicken and adhere extensively. Can cause pericardial occlusion, and even pleural chest wall adhesion, clinically known as constrictive pericarditis or Pick (Pick) disease, the degree of pericardial thickening varies, severe cases of pericardium up to 2cm Occasionally pericardium calcification.
Prevention
Tuberculous pericarditis prevention
1. Control the source of infection and reduce the chance of infection. The positive smear of tuberculosis is the main source of tuberculosis. Early detection and rational treatment of smear-positive tuberculosis patients are the basic measures to prevent tuberculosis. Infants and young children suffer from active tuberculosis, and their family members should For detailed examination (photographing chest, PPD, etc.), regular physical examinations should be conducted for primary and child care institutions to detect and isolate infection sources in a timely manner, which can effectively reduce the chance of tuberculosis infection.
2. Popularization of BCG vaccination has proved that vaccination with BCG is an effective measure to prevent tuberculosis in children. BCG was invented by French physicians Calmette and Guerin in 1921, so it is also called BCG. In China, it is prescribed to inoculate BCG in the neonatal period. The upper left deltoid muscle was injected intradermally at a dose of 0.05 mg/time. The scratch method is now rarely used. The Ministry of Health notified in 1997 to cancel the 7-year-old and 12-year-old BCG re-integration plan, but if necessary, the age-related Children who are negative in the test may still be given multiple cropping. In the neonatal period, BCG can be injected on the same day as the hepatitis B vaccine.
Contraindications to vaccination with BCG: positive lignin response; patients with eczema or skin disease; recovery period of acute infectious disease (1 month); congenital thymic dysplasia or severe combined immunodeficiency disease.
3. Prophylactic chemotherapy is mainly used for the following subjects:
(1) Infants under the age of 3 have not been vaccinated with BCG and have a positive test.
(2) Close contact with patients with open tuberculosis (multiple family members).
(3) The sputum test has recently changed from negative to positive.
(4) The sputum test is a strong positive responder.
(5) The positive test of the lignin requires a longer-term use of adrenocortical hormone or other immunosuppressive agents.
Complication
Tuberculous pericarditis complications Complications, cardiogenic cirrhosis, edema
Common complications of this disease include cardiac tamponade and cardiogenic cirrhosis.
1. Cardiac tamponade with tuberculous pericarditis has a large amount of pericardial effusion, but the rate of formation is slow, generally does not cause acute hemodynamic complications, such as acute pericardial tamponade, but may have symptoms and signs of chronic pericardial tamponade, It is a low pressure tampon.
2. Cardiac cirrhosis due to chronic pericardial constriction, hypertrophy, stiff pericardium limits ventricular filling, right ventricular diastolic pressure and right atrial pressure rise, obstruction of hepatic venous return, intrahepatic sinus expansion and congestion, oppression of adjacent Hepatocytes promote hepatocyte atrophy and accelerate fibrous tissue hyperplasia. In addition, hepatic sinus permeability increases, high protein fluid infiltrates into the Disse cavity, and edema of the paranasal sinus, which hinders the diffusion of nutrients from the plasma into the liver cells, aggravating liver damage. Finally, cardiogenic cirrhosis is formed.
Symptom
Tuberculous pericarditis symptoms common symptoms tachycardia dyspnea palpitations pulse small odd pulse bloody exudate jugular vein anger thinning night sweats sitting breathing
Most of the patients are young, more common in men, slow onset, mainly non-specific systemic symptoms, often have fever, chest pain, palpitations, cough, difficulty breathing, loss of appetite, weight loss and night sweats, etc., often occur in the pericardial exudate stage In the late stage of constrictive pericarditis, chest pain is milder than acute viral or non-specific myocarditis. If combined with tuberculosis, there may be cough and hemoptysis.
The main signs of tuberculous pericarditis are: tachycardia, heart expansion, heart sounds distant, occasional pericardial friction, 40% to 50% and pleural effusion, a large number of people can cause cardiac tamponade, can appear jugular vein engorgement, Qimai, liver enlargement, sitting breathing, lower extremity edema, etc. There are a group of foreign reports of 88 cases of tuberculous pericarditis, 88% have jugular vein engorgement, 95% have hepatomegaly, 73% have ascites, and 18% have pericardium. Friction sound, half of the cases of chest X-ray showed heart enlargement and pleural effusion.
Tuberculous pericarditis develops chronic constrictive pericarditis without fever, night sweats and other symptoms, but prominent manifestations of jugular vein engorgement, hypotension and pulse pressure, abdominal distension, ascites and edema.
Early diagnosis is very important. Any patient with unexplained fever, a large amount of pericardial effusion, especially bloody exudate should first think of tuberculous pericarditis. It is worth noting that tuberculous pericarditis may also occur during the treatment of tuberculosis. The exact diagnosis of tuberculous pericarditis is difficult to determine by bacteriology, because the rate of bacterial growth in pericardial effusion is very low, it is not easy to be stained or microscopically detected, and it takes a long time to obtain acid-fast bacilli culture, and the positive rate is also low. In the early stage, acid-fast bacilli can be found in pericardial effusion or pericardial biopsy specimens, and the diagnosis can be confirmed. It should be emphasized that the limitations of the biopsy site, negative pericardial biopsy can not exclude tuberculous pericarditis; No acid-fast bacilli are seen in swollen or cheese-like substances, and a positive diagnosis of tuberculous pericarditis cannot be made, as these substances may also be seen in chronic rheumatoid or sarcoma-like pericardial lesions for cardiac tamponade or Pericardial puncture should be performed for pericardial effusions with a course of at least 1 week. The patient's sputum and gastric aspirate specimens should be examined. Nuclear bacteria, surgical pericardial biopsy can be performed under the following conditions: 1 relieve cardiac tamponade; 2 hospitalized for more than 3 weeks, the cause of the diagnosis is unknown, or blind anti-tuberculosis treatment for more than 5 weeks still have fever and pericardial effusion, in the acute cause of unknown For patients with pericarditis, laboratory tests should include tuberculin skin tests. It should also be noted that negative tuberculosis skin test alone does not negate tuberculous pericarditis because about 30% of tuberculosis patients are unresponsive and negative. Elevated adenosine deaminase activity (ADA) in pericardial effusion (normal <45U/L) contributes to the diagnosis of tuberculous pericarditis. Therefore, the clinical diagnosis of tuberculous pericarditis is Necessary, but need to be carefully identified, on the one hand should not ignore the serious tuberculosis patients, on the other hand, do not put non-tuberculosis patients in the long-term treatment of a variety of anti-tuberculosis drugs.
Examine
Tuberculous pericarditis examination
1. The tuberculin test positive for tuberculin test and the presence of tuberculosis in other parts of the body are helpful for diagnosis, and 25% of patients have negative tuberculin test.
2. Pericardial puncture fluid examination is similar to tuberculous pleurisy exudate, may have bloody pericardial effusion, confirmed tuberculosis bacteria found in pericardial effusion, but the positive rate is low, 20% to 50% cases of Mycobacterium tuberculosis culture positive, pericardial fluid A significant increase in adenosine deaminase ADA is helpful in diagnosis.
3. Pericardial biopsy can be seen in cheese-like granulation tissue, the positive rate is 50% to 75%.
4. X-ray examination is very important for the determination of pericardial effusion. When the effusion>300500ml, the heart shadow expands into pear shape or flask shape under fluoroscopy, the original arc disappears, the heart beats weakened or disappeared, and the bottom of the heart shadow Widened, spherical, the aorta becomes smaller and the superior vena cava becomes wider, and the radiography is helpful for diagnosis.
5. ECG examination
(1) ST segment elevation: early (hours to days) except for aVR, the ST segment of V1 drops, the ST segment of other leads is elevated, with V5, V6 obvious, the arch back is downward, and then gradually declines, back To the equipotential line.
(2) T wave change: the early T wave is erect. When the ST segment returns to the baseline, the T wave is gradually flattened or inverted. After the inflammation subsides (weeks to several months), the T wave gradually returns to normal, such as turning chronic. T wave inversion can exist for a long time.
(3) It can be seen that the QRS complex wave is low voltage.
(4) sinus tachycardia.
(5) A large number of pericardial effusions can cause electrical alternating of P, QRS and T waves, and right bundle branch block can occur.
6. Echocardiography can detect 15ml of effusion, there is an echo-free liquid dark area between the posterior wall of the left ventricle and the posterior pericardium; similarly, there may be such darkness between the anterior wall of the right ventricle and the chest wall. The area exists.
4. Isotope scanning intravenous injection of 131I-labeled albumin or intravenous injection of 99mTc for cardiac scan, compared with the heart shadow of X-ray films, can determine the presence or absence of exudate. 7
Diagnosis
Diagnosis and diagnosis of tuberculous pericarditis
In the pre-cardiac area, the pericardial friction sound is heard, and the diagnosis of pericarditis can be established.
In the course of a disease that may be complicated by pericarditis, such as chest pain, dyspnea, tachycardia and unexplained systemic venous congestion or enlarged heart, should be considered for pericarditis with the possibility of exudate, oozing pericarditis and The identification of cardiac enlargement caused by other causes often difficulties, the jugular vein is dilated with odd veins, the apex beats weakly, the heart sound is weak, there is no valve murmur, and there is extra early diastolic sound.
X-ray examination or cardiac phonography shows that the normal contour of the heart disappears, the pulsation is weak; the electrocardiogram shows low voltage, the ST-T changes and the QT interval does not prolong, which is beneficial to the diagnosis of the former, and can be used for ultrasonic examination and radionuclide examination. And magnetic resonance imaging, etc., pericardial puncture and pericardial biopsy can help to confirm the diagnosis, the severe pain of non-specific pericarditis is similar to acute myocardial infarction, but the former often has a history of upper respiratory tract infection before onset, pain due to breathing, cough or body position change Significantly increased, early pericardial friction sound, serum aspartate transferase, lactate dehydrogenase and creatine phosphokinase normal, ECG no abnormal Q wave; the latter age of onset, often have a history of angina or myocardial infarction, pericardial friction Occurred 3 to 4 days after onset, ECG has abnormal Q wave, ST segment elevation and T wave inversion, etc., often have severe arrhythmia and conduction block, such as acute pericarditis pain Abdominal, may be misdiagnosed as acute abdomen, detailed medical history and physical examination can avoid misdiagnosis, the clinical manifestations of pericarditis of different causes are different, The treatment is also different. Therefore, after the diagnosis of acute pericarditis is established, it is necessary to further clarify the cause and provide direction for treatment.
