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Submitted in partial fulfilment of the requirements for the Degree of Masters in Technology: Clinical Technology, Durban University of Technology, 2013. / Introduction : Effusive constrictive pericarditis (ECP) is a clinical syndrome characterized by concurrent pericardial effusion and pericardial constriction where constrictive haemodynamics are persistent after the pericardial effusion is removed. Although first observed in the 1960s, it was not until the publication of a 13 patient-case series by Hancock in 1971, and the prospective cohort publication by Sagrista-Sauleda in 2004, that more information about the aetiology, incidence, and prognosis of effusive-constrictive pericarditis became known (Sagrista-Sauleda, Angel, Sanchez, Permanyer-Miralda, and Soler-Soler 2004). Hancock (1971) first recognized that some patients presenting with cardiac tamponade did not have resolution of their elevated right atrial pressure after removal of the pericardial fluid. In these patients, pericardiocentesis converted the haemodynamics from those typical of tamponade to those of constriction. Thus, the restriction of cardiac filling was not only due to the pericardial effusion but also resulted from pericardial constriction (predominantly the visceral pericardium). The hallmark of effusive-constrictive pericarditis is the persistence of elevated right atrial pressures after the intrapericardial pressure has been reduced to normal levels by the removal of the pericardial fluid. Aims and Objectives : This study was carried out to determine the prevalence of ECP in a cohort of patients with large effusions of Tuberculosis origin. The primary objective was to measure pre and post- pericardiocentesis intrapericardial and right atrial cardiac pressures in all patients undergoing pericardiocentesis in order to determine the relative proportion of effusive constrictive pericarditis in these patients. The secondary objective was to determine if any echocardiographic features can help predict the presence of ECP by studying the three parameters two-week post-pericardiocentesis. Methodology : Fifty consecutive patients with pericarditis presenting to Groote Schuur Hospital and surrounding hospitals referred for pericardiocentesis, who met the inclusion criteria were recruited to participate in the study. All patients had the right atrial and intrapericardial pressures simultaneously measured and recorded, before and after pericardiocentesis. The pressures were analyzed to determine the presence of ECP, which was defined as failure of the right atrial pressure to fall by 50% or to a new level of ≤12 mmHg after the intrapericardial pressure is lowered to below 2 mmHg. Participants also had an echocardiogram done two weeks post pericardiocentesis. Three echocardiographic features of constriction were studied, to determine if they can predict the presence of ECP. The parameters studied were 1) Thickened pericardium, 2) Dilated inferior vena cava (IVC) and 3) Septal bounce. Results : This study showed a 34% (17 0f 50) prevalence of ECP in patients with TB pericarditis. It also showed a statistically difference in the right atrial and intrapericardial pressures pre and post pericardiocentesis, between patients with ECP and those without. The echocardiographic parameters studied showed no difference between ECP and non ECP, and also did not predict the presence of ECP. Discussion : In the cohort of patients (n=50), the prevalence of ECP was found to be 34%. This is much higher than that observed in the Sagrista-Sauleda et al., (2004) study. They found a prevalence of 1.3% amongst patients with pericardial disease of any type and 6.95% amongst patients with clinical tamponade. The authors did state that they expected the true prevalence to be higher than estimated as not all patients underwent catheterization. Pre-pericardiocentesis pressures, both right atrial and intrapericardial, were found to be higher in patients with ECP than in those without. This is in keeping with published results, such as the study of Hancock (1971) The echocardiographic parameters studied were two weeks post pericardiocentesis, because the diagnostic accuracy of echocardiogram has been shown to be very poor at the time of tamponade. The presence of these parameters (thickened pericardium, dilated IVC and septal bounce), did not predict the presence of ECP. This could be due to the fact that less than 50% of participants had an echocardiogram two weeks post pericardiocentesis. Conclusions : The results of this study show that ECP is actually more common than thought in a population with TB pericarditis. This syndrome may be missed in most patients due to the fact that not all centres measure right atrial and intrapericardial pressures at the time of pericardiocentesis. Echocardiography is not able to predict the presence of ECP. Other non-invasive imaging techniques such is computerized tomography (CT) and cardiac magnetic resonance imaging (CMRI) have shown good results in diagnoses of ECP. The importance of early diagnosis of ECP lies in recognition that removal of pericardial fluid alone may not be enough; patients may need to have surgery. Given the high prevalence shown by the study, ideally all patients with pericardial effusion should have haemodynamic monitoring at the time of pericardiocentesis.

Introduction: Tuberculosis (TB) pericarditis is a relatively rare form of tuberculosis which has been on the decline. However, the advent of the human immunodeficiency virus (HIV) pandemic has brought about the resurgence of tuberculosis pericarditis and an even poorer prognosis for patients with HIV co-infection. Objectives: The aim is to describe the baseline characteristics of tuberculous pericarditis patients and to assess the impact of HIV on the clinical presentation of this disease. Methods: The study describes baseline data from a randomised clinical trial which explored the use of adjunctive corticosteroids in management of TB pericarditis then went on to compare HIV co-infected patients versus those without HIV co-infection using logistic regression. Results: There were 1394 patients enrolled into the study, 64% were HIV positive, 19% were HIV negative and 17% had an unknown HIV status. Forty four percent of the participants were female and age had a positively skewed distribution with median 36 years (IQR: of 29-46). HIV co-infected patients were younger with OR 0.97(95% CI: 0.96-0.98), more likely to have previously had TB with OR 2.15(95% CI: 1.25-3.72), had a more acute illness with OR 0.99(95% CI: 0.99-1.00), had lower hemoglobin with OR 0.72(95% CI: 0.67-0.78), lower White Cell Count, (WCC) with OR 0.90(95% CI: 0.86-0.96) and higher globulin with OR 1.07(95% CI: 1.05-1.09). Conclusion: HIV co-infected participants are younger, more likely to have been previously diagnosed with TB, have a more acute illness, lower haemoglobin, lower WCC and higher globulin. / Dissertation (MSc)--University of Pretoria, 2013. / School of Health Systems and Public Health (SHSPH) / unrestricted

Background: Since constrictive pericarditis is most often idiopathic and the pathophysiology remains largely unknown, both the diagnosis and the treatment can be challenging. However, by definition, inflammatory processes are central to this disease process. Amniotic membrane patches have been shown to possess anti-inflammatory properties and are believed to be immune privileged. Due to these properties, amniotic membrane patches were applied intraoperatively in a complicated patient presenting with constrictive pericarditis. Case presentation: A patient with a history of multiple cardiac surgeries presented with marked fatigue, worsening dyspnea and sinus tachycardia. He was found to have constrictive physiology during cardiac catheterization, with cardiac MRI demonstrating hepatic vein dilatation, atrial enlargement and ventricular narrowing. After amniotic membrane patch treatment and pericardiectomy, post-operative cardiac MRI failed to demonstrate any appreciable pericardial effusion or inflammation, with no increased T2 signal that would suggest edema. Conclusions: Given the positive results seen in this complex patient, we suggest continued research into the beneficial properties of amniotic membrane patches in cardiac surgery.

A 67-year-old male patient received a coronary artery bypass graft. Less than 2 months afterward, he presented with recurrent exacerbations of congestive heart failure. His response to a standard treatment regimen for heart failure was partly successful, but a few days after discharge he was readmitted for worsening dyspnea and edema. Doppler echocardiography suggested the hemodynamics of constrictive pericarditis. Magnetic resonance imaging showed thickened pericardium with exudates in the pericardial space. Cardiac catheterization confirmed the diagnosis, showing equalization of diastolic pressures of the left and right ventricles. The patient underwent subtotal pericardiectomy with resolution of the pericardial disease, but he died from respiratory insufficiency.

In this MMed thesis I have reviewed retrospectively the pericardial aspirations performed between 1 July 1987 and 12th October 1989 at Groote Schuur Hospital, Cape Town. Documenting the reasons for aspiration, the complications of pericardiocentesis, and how cytologic, bacteriologic and biochemical examination of the aspirate influenced the clinicians' management of the 52 patients reviewed. The relatively low mortality of less than 2% is noted, in a procedure carried out for the relief of cardiac tamponade in 57% of the patients. A significant relationship between an ADA level higher than 51 international units per litre and a positive culture of mycobacterium tuberculosis from pericardial aspiration is demonstrated. The relatively low successful culture of mycobacterium tuberculosis (32% of the 29 patients clinically assessed as having tuberculous pericarditis) is noted, and recommendations to improve the yield from culture are made.

Constrictive pericarditis arises as a result of the fibrous thickening of the pericardium due to chronic inflammatory changes from various injuries. Increased pulmonary and systemic venous pressures manifest clinical features of left and right heart failure. Idiopathic or post-viral pericarditis is the most common cause followed by postpericardiotomy, radiation-induced causes. Right-sided heart failure symptoms predominate over left-sided heart failure symptoms due to the equalization of pressures. No single diagnostic test can provide a definitive diagnosis or evidence of constrictive pericarditis. Medical management is difficult for constrictive pericarditis. The treatment of choice for constrictive pericarditis is pericardiectomy.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

O presente trabalho avaliou corações com pericardite e pulmões correspondentes através da análise anatomopatológica, bacteriológica, histopatológica e da técnica da Reação em Cadeia da Polimerase (PCR) a fim de identificar os agentes envolvidos no processo e correlacioná-los com as lesões macroscópicas presentes. O estudo foi realizado em quatro frigoríficos do estado do Rio Grande do Sul com o apoio do Serviço de Inspeção Federal (SIF) durante o período de fevereiro a outubro de 2010. Foram coletadas 120 amostras de corações com pericardite e pulmões correspondentes e avaliadas 3.487 carcaças na linha de inspeção em 20 lotes diferentes, totalizando 8 coletas. Os materiais foram examinados nos laboratórios de Microbiologia, Biologia Molecular e Patologia Veterinária da Faculdade de Veterinária da Universidade Federal do Rio Grande do Sul. Entre as pericardites, 86,7% foram classificadas como fibrinosas (104/120), 6,7% serosas (8/120), 2,5% (3/120) sero-fibrinosas e 4,2% (5/120) amostras não puderam ser classificadas. Foram diagnosticadas lesões de endocardite em somente 2,5% (3/120) dos corações. Quanto aos pulmões analisados, as alterações macroscópicas mais encontradas foram 66,6% (80/120) aderências de pleura direita e/ou esquerda, 19,1% (23/120) hepatizações dos lobos apicais direito e 5,83% (7/120) do esquerdo, 23,33% (28/120) do lobo cardíaco direito e 23,33% (28/120) do esquerdo. Pela análise histopatológica do coração, a lesão mais frequente foi presença de tecido de granulação denso fibroso e em algumas amostras tecidos de granulação frouxo, com proliferação de vasos em ambos os casos. Havia presença de fibrina e células inflamatórias mononucleares em alguns casos. Na análise dos pulmões correspondentes, 70% (84/120) das amostras de pulmões apresentavam algum tipo de lesão aparente. As lesões mais comuns foram pleurite crônica, hiperplasia das células do tecido linfóide associado aos brônquios (BALT), presença de macrófagos alveolares e broncopneumonia purulenta. Não foram observadas lesões microscópicas em 23,3% (28/120) dos pulmões e 6,6% (8/120) não foram coletados para análise devido a cronicidade da lesão. A análise da carcaça mostrou pleurite parietal em 12,5% (15/120) e algum tipo de envolvimento articular em 1,6 % (2/120) dos animais, não sendo objetivo avaliar o tipo de lesão e sim uma possível correlação com Haemophilus parasuis. Das análises bacteriológicas dos corações, obteve-se um maior número de isolados de Pasteurella multocida 16% (20/120), seguido de Streptococcus spp. 17,3% (6 /120) e 5% (6/120) Haemophilus parasuis. A maior parte dos isolados foi obtida das pericardites fibrinosas. Com relação aos pulmões correspondentes, foram isolados 17,5% (22/120) Pasteurella multocida, 51.57% (8/120) Streptococcus spp., e 0,8% (1/120) Haemophilus parasuis. Entre os isolados de P. multocida foi realizada a tipificação capsular das cepas identificadas no pulmão e coração através da PCR e todas pertenciam ao tipo A. Na técnica da PCR no coração pode-se observar um grande número de M. hyopneumoniae 34,8% (39/112), seguido de A. pleuropneumoniae 23,2% (26/112), H. parasuis 6,2% (7/112), P. multocida tipo A 3,5% (4 /112) e M. hyorhinis 2,6% (3/112). A mesma técnica aplicada aos pulmões correspondentes, revelou M. hyopneumoniae 81,2% (91 /112), H. parasuis 36,6 % (41 /112), A. pleuropneumoniae 33,9% (38/112), P. multocida tipo A 30,3% (34/112), M. hyorhinis 9.8% (11/112). / The present work assessed hearts with pericarditis and the corresponding lungs through visual analysis of gross lesions, bacteriology, histopathology and polymerase chain reaction (PCR) to identify agents involved in the processes and to correlate them with the lesions. The study was carried out in four slaughterhouses from the state of Rio Grande do Sul, Brazil, with the help of the Service of Federal Inspection (SIF) during the period of February to October, 2010. Samples of 120 hearts with pericarditis and corresponding lungs were collected and examined, and 3.487 carcasses were assessed in the slaughter line in 20 different batches, in a total of 8 sample collections. Materials were examined in the laboratories of Microbiology, Molecular Biology and Pathology of the Faculdade de Veterinária da Universidade Federal do Rio Grande do Sul, Brazil. Among the samples with pericarditis, 104 were classified as fibrinous (86.7%), 8 serous (6.7%), 3 sero-fibrinous (2.5%) and 5 remained unclassified (4.2%). Lesions of endocarditis were present in 3 hearts (2.5%). Regarding lungs, the commonest gross changes were 80 pleural adhesions (66.6%) and 23 consolidations of the right apical lobes of the lung (19.1%) and 7 (5,83%) of the left; 28 (23,33%) from right cardiac lobe and 28 (23,33%) of left. Using histopathological analysis of the heart, the most frequent lesions were the presence of dense fibrous granulomatous tissue and, in some samples, loose granulation tissue, with of vessels proliferation in both cases. It was also found fibrin and inflammatory mononuclear cells in some cases. In the analysis of the corresponding lungs, 84 (70%) of the samples showed some type of apparent lesion. Te most prevalent lesions were chronic pleuritis, hyperplasia of lymphoid tissue cells associated to bronchia (BALT), presence of lung macrophages and purulent bronchopneumonia. Twenty eight lungs (23.3%) did not show any microscopic lesion and 8 (6.6%) were not collected because of the chronicity of the lesion. The analysis of the carcass showed parietal pleurisy in 15 (12.5 %) and joint involvement in 2 (1.6 %), but the present study did not intend to assess such lesions but a possible correlation with Haemophilus parasuis infection. Regarding bacteriological examination of the heart, Pasteurella multocida was the biggest isolation rate 16% (20/120), followed by Streptococcus spp 17.3% (6 /120) and 5% (6/120) Haemophilus parasuis. Most isolates were obtained from fibrinous pericarditis. Regarding the corresponding lungs, Pasteurella multocida was isolated in 17.5% (22/120) materials, Streptococcus spp in 51.57% (8/120), and Haemophilus parasuis in 0.8% (1/120). Pasteurella multocida capsular typing was carried out from strains identified through PCR from heart and lungs, all belonged to the serotype A. By PCR from samples from pericarditis a large number of M. hyopneumoniae was detected: 34. 8% (39/112), followed by APP 23.2% (26/112), H. parasuis 6.2% (7/112), P. multocida type A 3.5% (4 /112) and M. hyorhinis 2.6% (3/112). The same technique applied to the corresponding lungs, showed M. hyopneumoniae in 81.2% (91 /112), H. parasuis in 36.6 % (41 /112), APP in 33.9% (38/112), P. multocida type A in 30.3% (34/112) and M. hyorhinis in 9.8% (11/112).

O presente trabalho avaliou corações com pericardite e pulmões correspondentes através da análise anatomopatológica, bacteriológica, histopatológica e da técnica da Reação em Cadeia da Polimerase (PCR) a fim de identificar os agentes envolvidos no processo e correlacioná-los com as lesões macroscópicas presentes. O estudo foi realizado em quatro frigoríficos do estado do Rio Grande do Sul com o apoio do Serviço de Inspeção Federal (SIF) durante o período de fevereiro a outubro de 2010. Foram coletadas 120 amostras de corações com pericardite e pulmões correspondentes e avaliadas 3.487 carcaças na linha de inspeção em 20 lotes diferentes, totalizando 8 coletas. Os materiais foram examinados nos laboratórios de Microbiologia, Biologia Molecular e Patologia Veterinária da Faculdade de Veterinária da Universidade Federal do Rio Grande do Sul. Entre as pericardites, 86,7% foram classificadas como fibrinosas (104/120), 6,7% serosas (8/120), 2,5% (3/120) sero-fibrinosas e 4,2% (5/120) amostras não puderam ser classificadas. Foram diagnosticadas lesões de endocardite em somente 2,5% (3/120) dos corações. Quanto aos pulmões analisados, as alterações macroscópicas mais encontradas foram 66,6% (80/120) aderências de pleura direita e/ou esquerda, 19,1% (23/120) hepatizações dos lobos apicais direito e 5,83% (7/120) do esquerdo, 23,33% (28/120) do lobo cardíaco direito e 23,33% (28/120) do esquerdo. Pela análise histopatológica do coração, a lesão mais frequente foi presença de tecido de granulação denso fibroso e em algumas amostras tecidos de granulação frouxo, com proliferação de vasos em ambos os casos. Havia presença de fibrina e células inflamatórias mononucleares em alguns casos. Na análise dos pulmões correspondentes, 70% (84/120) das amostras de pulmões apresentavam algum tipo de lesão aparente. As lesões mais comuns foram pleurite crônica, hiperplasia das células do tecido linfóide associado aos brônquios (BALT), presença de macrófagos alveolares e broncopneumonia purulenta. Não foram observadas lesões microscópicas em 23,3% (28/120) dos pulmões e 6,6% (8/120) não foram coletados para análise devido a cronicidade da lesão. A análise da carcaça mostrou pleurite parietal em 12,5% (15/120) e algum tipo de envolvimento articular em 1,6 % (2/120) dos animais, não sendo objetivo avaliar o tipo de lesão e sim uma possível correlação com Haemophilus parasuis. Das análises bacteriológicas dos corações, obteve-se um maior número de isolados de Pasteurella multocida 16% (20/120), seguido de Streptococcus spp. 17,3% (6 /120) e 5% (6/120) Haemophilus parasuis. A maior parte dos isolados foi obtida das pericardites fibrinosas. Com relação aos pulmões correspondentes, foram isolados 17,5% (22/120) Pasteurella multocida, 51.57% (8/120) Streptococcus spp., e 0,8% (1/120) Haemophilus parasuis. Entre os isolados de P. multocida foi realizada a tipificação capsular das cepas identificadas no pulmão e coração através da PCR e todas pertenciam ao tipo A. Na técnica da PCR no coração pode-se observar um grande número de M. hyopneumoniae 34,8% (39/112), seguido de A. pleuropneumoniae 23,2% (26/112), H. parasuis 6,2% (7/112), P. multocida tipo A 3,5% (4 /112) e M. hyorhinis 2,6% (3/112). A mesma técnica aplicada aos pulmões correspondentes, revelou M. hyopneumoniae 81,2% (91 /112), H. parasuis 36,6 % (41 /112), A. pleuropneumoniae 33,9% (38/112), P. multocida tipo A 30,3% (34/112), M. hyorhinis 9.8% (11/112). / The present work assessed hearts with pericarditis and the corresponding lungs through visual analysis of gross lesions, bacteriology, histopathology and polymerase chain reaction (PCR) to identify agents involved in the processes and to correlate them with the lesions. The study was carried out in four slaughterhouses from the state of Rio Grande do Sul, Brazil, with the help of the Service of Federal Inspection (SIF) during the period of February to October, 2010. Samples of 120 hearts with pericarditis and corresponding lungs were collected and examined, and 3.487 carcasses were assessed in the slaughter line in 20 different batches, in a total of 8 sample collections. Materials were examined in the laboratories of Microbiology, Molecular Biology and Pathology of the Faculdade de Veterinária da Universidade Federal do Rio Grande do Sul, Brazil. Among the samples with pericarditis, 104 were classified as fibrinous (86.7%), 8 serous (6.7%), 3 sero-fibrinous (2.5%) and 5 remained unclassified (4.2%). Lesions of endocarditis were present in 3 hearts (2.5%). Regarding lungs, the commonest gross changes were 80 pleural adhesions (66.6%) and 23 consolidations of the right apical lobes of the lung (19.1%) and 7 (5,83%) of the left; 28 (23,33%) from right cardiac lobe and 28 (23,33%) of left. Using histopathological analysis of the heart, the most frequent lesions were the presence of dense fibrous granulomatous tissue and, in some samples, loose granulation tissue, with of vessels proliferation in both cases. It was also found fibrin and inflammatory mononuclear cells in some cases. In the analysis of the corresponding lungs, 84 (70%) of the samples showed some type of apparent lesion. Te most prevalent lesions were chronic pleuritis, hyperplasia of lymphoid tissue cells associated to bronchia (BALT), presence of lung macrophages and purulent bronchopneumonia. Twenty eight lungs (23.3%) did not show any microscopic lesion and 8 (6.6%) were not collected because of the chronicity of the lesion. The analysis of the carcass showed parietal pleurisy in 15 (12.5 %) and joint involvement in 2 (1.6 %), but the present study did not intend to assess such lesions but a possible correlation with Haemophilus parasuis infection. Regarding bacteriological examination of the heart, Pasteurella multocida was the biggest isolation rate 16% (20/120), followed by Streptococcus spp 17.3% (6 /120) and 5% (6/120) Haemophilus parasuis. Most isolates were obtained from fibrinous pericarditis. Regarding the corresponding lungs, Pasteurella multocida was isolated in 17.5% (22/120) materials, Streptococcus spp in 51.57% (8/120), and Haemophilus parasuis in 0.8% (1/120). Pasteurella multocida capsular typing was carried out from strains identified through PCR from heart and lungs, all belonged to the serotype A. By PCR from samples from pericarditis a large number of M. hyopneumoniae was detected: 34. 8% (39/112), followed by APP 23.2% (26/112), H. parasuis 6.2% (7/112), P. multocida type A 3.5% (4 /112) and M. hyorhinis 2.6% (3/112). The same technique applied to the corresponding lungs, showed M. hyopneumoniae in 81.2% (91 /112), H. parasuis in 36.6 % (41 /112), APP in 33.9% (38/112), P. multocida type A in 30.3% (34/112) and M. hyorhinis in 9.8% (11/112).