tuberculous pericarditis in children
Introduction
Introduction to tuberculous pericarditis in children Tuberculous pericarditis in China occupies an important position in pericardial diseases, accounting for 21.3% to 35.8% of pericardial diseases. At present, the incidence of tuberculosis in the world is increasing. Human immunodeficiency virus (HIV) transmission is one of the main causes. Tuberculous pericarditis is not rare in clinical practice. It is more common in school-age children. Tuberculous pericarditis can be divided into exudative And narrowing two types. 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. basic knowledge The proportion of illness: the probability of illness in infants and young children is 0.0031% Susceptible people: children Mode of infection: non-infectious Complications: Cardiogenic cirrhosis, edema
Cause
Causes of tuberculous pericarditis in children
Cause:
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.
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
Prevention of tuberculous pericarditis in children
1. Control the source of infection and reduce the chance of infection. The positive smear of tuberculosis is the main source of tuberculosis in children. Early detection and rational treatment of smear-positive tuberculosis patients is a fundamental measure to prevent tuberculosis in children. Members should conduct detailed examinations (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 in children.
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) Children with positive serotonin test need to use adrenocortical hormone or other immunosuppressive agents for a longer period of time.
The drug used for chemopreventive drugs is mainly isoniazid, the dose is 10mg/(kg·d), the course of treatment is 6-9 months, the newborns of the newly born tuberculosis parents under the age of 6 and the newborns born to the tuberculosis women, regardless of the knot If the results of the test are all the same, the isoniazid should be given. The dose is the same as above. After 3 months of administration, the test is performed. If it is positive, the isoniazid is continued for 9 months; if the test is negative (<5mm) ), then stop the isoniazid.
Anti-HIV-positive children with a history of tuberculosis should receive isoniazid for 12 months regardless of the outcome of the nodule test.
If the tuberculosis patient contacted by children is resistant to isoniazid, the chemotherapeutic drug should be changed to rifampicin, 15mg/(kg·d), 6-9 months; if it is resistant to isoniazid and resistant to rifampicin, It is recommended to give pyrazinamide plus ofloxacin for 6 to 9 months, or pyrazinamide plus ethambutol for 6 to 9 months.
Complication
Complications of tuberculous pericarditis in children 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 in children Common symptoms Unexplained fever, jugular vein anger, pericardial fiber thickening, hoarseness, pericardial effusion, hypoproteinemia, high fever, liver-jugular reflux, positive dull pain, dry cough
1. Exudative tuberculous pericarditis: Onset can be acute and slow, as short as several days, for several months, the length of the disease is related to the amount of exudate in the pericardial cavity and the rate of production, the patient may have fever, more For low fever, a few cases can be hyperthermia, the early symptoms are mainly pain, mainly under the sternum, mostly dull pain or chest tightness. It is worth noting that patients with tuberculous pericarditis are far less painful than acute non-specific pericarditis and suppurative pericardium. Inflammation is obvious and severe. When the amount of pericardial effusion is large, symptoms of cardiac and vena cava compression may occur, such as dry cough, hiccup, hoarseness and lower extremity edema. The common heart is more than moderately increased in the heart, the apex is weakened, and the heart sound is far away. Running horse, liver enlargement, ascites, lower extremity edema, jugular vein engorgement, odd pulse, small pulse pressure, expansion of jugular vein inhalation, positive liver-jugular venous return, due to pericardial effusion pressure forced left lung bottom, There may be dullness, bronchial breath sounds and other signs of lung consolidation in the lower left back, but when the onset is slow, the exudate is less or a large amount of accumulation is very slow, there is no obvious cardiac tamponade symptoms, about half of the patients suffer from In the early stage of inflammation, the pericardial friction sound can be heard, and the venous pressure is significantly increased.
2. Constrictive pericarditis: slow onset, which can be caused by acute exudation type, but most cases are hidden due to acute stage, have not been found, have formed narrowing at the time of treatment, and the duration of the disease can be several months to several Years, but there are also less than 2 weeks of disease, the pericardium has thickened to form constrictive pericarditis, more common in older children, but the smallest case in our case is only 2 years old, confirmed by surgery, clinically, except for general symptoms, mainly dyspnea And a series of cardiac tamponade symptoms and signs, mainly manifested as large liver, followed by ascites, lower extremity edema, jugular vein engorgement, lung snoring and lip cyanosis, etc., there are also a few typical cases, cardiac tamponade symptoms are not obvious The pleural effusion, which has long-term unexplained causes, I have seen 1 case of tuberculous pleurisy in a foreign hospital for 8 months, eventually constrictive pericarditis, and another case of unexplained long-term hypoproteinemia. After diagnosis of tuberculous constrictive pericarditis, resulting in protein-losing enteropathy, a large number of proteins from the intestinal tract lost hypoproteinemia.
Examine
Examination of tuberculous pericarditis in children
1. Tuberculin test: The positive 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: similar to tuberculous pleurisy exudate, may have bloody pericardial effusion, confirmed tuberculosis in the pericardial effusion, but the positive rate is low, 20% to 50% of cases of Mycobacterium tuberculosis culture positive, pericardium A significant increase in adenosine deaminase ADA in the fluid is helpful for diagnosis.
3. Pericardial biopsy: can be seen in cheese-like granulation tissue, the positive rate is 50% to 75%.
4. X-ray examination: It is very important to determine the pericardial effusion. When the effusion>300500ml, the heart shadow expands into a pear shape or a flask shape under fluoroscopy. The original arc disappears, the heart beats weakened or disappeared, and the bottom of the heart is lying on the back. The shadow is widened and 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: 15ml of effusion can be detected, there is an echo-free liquid dark area between the posterior wall of the left ventricle and the posterior pericardium; similarly, there can be this between the anterior wall of the right ventricle and the chest wall. Dark areas exist.
7. Isotope scan: 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.
Diagnosis
Diagnosis and diagnosis of tuberculous pericarditis in children
Diagnostic criteria
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, in the following circumstances may apply surgical pericardial biopsy:
1 relieve heart tamponade
2 In the hospital for more than 3 weeks, the etiology diagnosis is unknown, or blind anti-tuberculosis treatment for more than 5 weeks still have fever and pericardial effusion. In patients with acute pericarditis who do not know the cause, laboratory tests should include tuberculin skin test, it should also be noted that Negative tuberculin skin test alone can not deny tuberculous pericarditis, because in tuberculosis patients, about 30% can be unresponsive and negative, and the adenosine deaminase activity (ADA) of pericardial effusion increases (Normal <45U/L) is helpful for the diagnosis of tuberculous pericarditis. Therefore, it is necessary to make an inferential diagnosis of tuberculous pericarditis clinically, but it needs to be carefully identified. On the one hand, TB patients with severe diseases should not be ignored. On the other hand, patients with non-tuberculosis should not be placed in long-term treatment of multiple anti-tuberculosis drugs.
Differential diagnosis
In the pre-cardiac area, the pericardial friction sound can be established, and the diagnosis of pericarditis can be established. In the process of possible pericarditis, such as chest pain, dyspnea, tachycardia and unexplained systemic venous congestion or enlarged heart, should be Considering the possibility of pericarditis accompanied by exudate, the differentiation of oozing pericarditis and other causes of cardiac enlargement often occurs, the jugular vein is dilated with odd veins, the apex beats weakly, the heart sound is weak, and there is no valve murmur. Early diastolic extra tone, X-ray examination or cardiac phonography shows that the normal contour of the heart disappears, the beat 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 further for ultrasound examination. Radionuclide examination and magnetic resonance imaging, 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, and the pain is caused by breathing. , cough or body position changes and significantly increased, early pericardial friction sound, as well as serum aspartate transferase, lactate dehydrogenase and creatine phosphate The kinase is normal, the electrocardiogram has no abnormal Q wave; the latter is older, often has a history of angina or myocardial infarction, the pericardial friction sound appears 3 to 4 days after onset, the electrocardiogram has abnormal Q wave, and the ST segment elevation of the arch back High and T wave inversion changes, often severe arrhythmia and conduction block, such as acute pericarditis pain mainly in the abdomen, may be misdiagnosed as acute abdomen, detailed medical history and physical examination can avoid misdiagnosis, different causes The clinical manifestations of pericarditis are different, and the treatment is different. Therefore, after the diagnosis of acute pericarditis is established, it is necessary to further clarify the cause and provide direction for treatment, and the differential diagnosis of four common acute pericarditis.
