A 54-year-old Sri Lankan man who had undergone live related renal transplantation for hemodialysis-dependent, end-stage, hypertensive nephrosclerosis presented to our institution with progressive New York Heart Association class III dyspnea and abdominal distention of several months' duration. At the time of presentation, he was in the sixth year after transplantation.
His pre-transplant evaluation had revealed refractory serous pericardial effusion despite normal serum albumin levels and intensive hemodialysis. Pericardial fluid taken at that time for acid-fast bacilli (AFB) smear and culture in Lowenstein-Jensen medium was negative, and there was no proof of TB elsewhere. On the basis of a strongly positive tuberculin skin test and the patient's symptoms, however, 6 months of a standard four-drug anti-TB regimen was commenced, which led to an excellent response prior to the transplantation procedure.
After the transplant, the patient had been started on routine immunosuppressive therapy with prednisolone, cyclosporine and mycophenolate mofetil. In the first 6 years following transplant, he achieved a good quality of life with a baseline creatinine level of 120mumol/L.
Upon the patient's presentation to our institution, his physical examination revealed engorged jugular veins in the neck, tense ascites with tender hepatomegaly, as well as mild bilateral pitting edema of the ankles. His heart sounds were normal, with no murmurs or added sounds. His respiratory system was clinically normal.
The patient's chest X-ray showed normal lung fields with a small heart shadow and no visible calcifications. Echocardiography revealed biatrial enlargement, left atrial diameter of 46mm, normal-size ventricles, good left ventricular function and a dilated inferior vena cava (27mm) with flow reversal. Paracentesis revealed the presence of transudate fluid. Subsequent cardiac catheterization showed early, rapid diastolic filling and equalization of pressure between the ventricles consistent with CP (Table 1). The patient's serum creatinine level was 212mumol/L at presentation.
He underwent an elective, uncomplicated total pericardiectomy, which provided symptomatic relief. Macroscopy revealed a very thick pericardium up to 15mm in some areas, causing constriction of all chambers of the heart. Histology showed a thick layer of fibrous tissue with early calcifications, but no granulomas or AFB (Figure 1). Analysis of pericardial tissue for Mycobacterium tuberculosis, including Ziehl-Neelsen stain, culture on Lowenstein-Jensen medium and polymerase chain reaction, was negative.
He was started on lifelong prophylactic isoniazid therapy. A follow-up echocardiogram taken 1 month after surgery was normal. At the 3-month post-operative examination, he had no significant symptoms and was able to walk briskly for 30 minutes on a flat surface. His graft function had improved markedly, and his serum creatinine level had dropped to 144mumol/L.