Patient information: a 16-year-old boy who was a student, was admitted to the medical unit of the Buea regional Hospital after he presented with a two week history of gradually worsening shortness of breath and abdominal distension, non-productive cough, loss of appetite and weight loss. These became associated with fever three days prior to admission. There were no night sweats, and no sputum. There was no history of trauma.
Clinical findings: on physical examination, his temperature was 36.7 C, respiratory rate was 24 breaths/minute, heart rate 98/minute; blood pressure 87/71mmHg. Cardiovascular examination was remarkable for distended neck veins, hepatojugular reflux and pulsus paradoxus. There was no lower extremity edema. The heart sounds were not muffled. There was no pericardial friction rub. Lung examination revealed bilateral pleural effusions. Abdominal examination revealed ascites and a tender hepatomegaly. There were neither lymphadenopathies nor palpable masses to suggest malignancy.
Diagnostic assessment: the chest x-ray showed an enlarged cardiac silhouette with bilateral pleural effusions. The HIV test was negative. The C-reactive protein was 24mg/l, erythrocyte sedimentation rate equal 45mm. Echocardiogram showed a large circumferential pericardial effusion with right ventricular diastolic collapse and marked variation in tricuspid and mitral inflow suggestive of cardiac tamponade (Figure 1). Echocardiographic guided pericardiocentesis was performed through the sub-xiphoid route and about 500cc of hemorrhagic fluid was drained which improved his symptoms. Fluid analysis was consistent with an exudative effusion. Acid fast bacilli stain was negative. Extensive evaluation of the etiology was not performed because of limited resources in this rural hospital. A strong suspicion of tuberculosis was made and a presumptive treatment for hemorrhagic tuberculous pericarditis was started.
Therapeutic intervention: pericardiocentesis was performed and the patient was placed on anti-tuberculosis medications.
Follow-up and outcomes: a follow-up echocardiography after two weeks did not show re-accumulation of the pericardial fluid (Figure 2). Clinically, the dyspnea had regressed. There were no signs of right sided heart failure and no signs of cardiac tamponade. He has no adverse effects from the medications.
Patient perspective: during the time he was hospitalized and after the treatment, the patient and his family were delighted with the care he received and was optimistic about the outcome of his condition.
Informed consent: the patient and the family were informed about the case report, why the case was peculiar and the authors' interest in publishing his case. The family willingly gave informed consent to allow the authors to use his echo images for this case report.
Patient's consent: informed consent was obtained from the family for us to use the echo images and to publish the case.