Patient information: a 31-year-old male (HIV negative), not known with any comorbidities, presented with 2 weeks history of difficulty in breathing, dry cough and low-grade fevers with progressive lower extremity swelling, exertional dyspnoea and air hunger at night. The symptoms started 2 weeks later after incision and drainage of a dental abscess. No history of chest trauma, B symptoms, no anaemia symptoms, no loss of consciousness, no change in micturition pattern. Other symptoms were unremarkable. He is a regular alcohol drinker and a non-smoker.
Clinical findings: on examination he was conscious, dyspnoeic, bilateral pitting oedema grade 4, saturation 97% 10L of O2, other vitals were stable. He had bilaterally reduced air entry, with distended neck veins, raised JVP by 6 cm, normal heart sounds. The abdomen was distended with positive shifting dullness.
Timeline of current episode: this can be seen in Figure 1.
Diagnostic assessment: blood workouts showed normocytic normochromic anaemia of 11.7, low albumin and protein with mild hyponatremia. Electrocardiogram (ECG) showed: sinus tachycardia with right axis deviation, chest X-ray (CXR) showed massive bilateral pleural effusion (Figure 2). The pleural tap showed ambercoloured 1.5L on the right and 400 MLS on the left. He was treated as a suspect of viral pneumonia with congestive heart failure with improvement (Lasix, Ceftriaxone Sulbactam, Ivermectin, Ascorbic Acid, Cholecalciferol, Dexamethasone, Zinc Sulphate and Colchicine). A few days after admission, the patient presented with signs of cardiac tamponade. An echocardiogram confirmed pericardial effusion. Pericardiocentesis was done, 950 mls pus drained (Figure 3), drainage was left in situ with improvement. AntiTB, prednisolone and omeprazole initiated. Culture and sensitivity, gene Xpert and ZN staining of pus were done which all came negative and there was no organism seen. Pericardial fluid glucose level was 1.01 mmol/L. CT Scan of the chest showed bilateral pleural effusion with partial atelectasis of both lungs right: 4.7L, left: 1.5L with thick pericardium about 6.9 mm (Figure 4), the pericardial tube was in situ, but no evidence of pericardial effusion.
Diagnosis: tuberculosis pericarditis; pulmonary tuberculosis.
Therapeutic interventions: pericardiectomy done, thick fibrotic pericardium encasing all the heart chambers was seen, excision of anterior and left pericardium done, pus and caseous material drained. Left pleural was normal. Post operative diagnosis: TB constrictive pericarditis; bilateral TB empyema thoracis. Histopathology analysis of Pericardial tissue showed: H & E stain showed mixed chronic inflammation and granulation tissue (Figure 5). Impression: non-specific chronic inflammation of the pericardium ZN Stain showed a thick fibrous wall of the pericardium with fibroblast proliferation and mononuclear cells infiltration but no rod-shaped Bacilli for Mycobacterium tuberculosis indicating ZN stain is negative (Figure 6).
Follow up and outcome of interventions: unfortunately, the patient died about 1-hour post-surgery due to anaesthesia complications.
Patient s perspective: unfortunately, the patient died about 1-hour post-surgery due to anaesthesia complications.
Informed consent: written informed consent was obtained.