Open Access Research article

Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry

Bongani M Mayosi1*, Charles Shey Wiysonge1, Mpiko Ntsekhe1, Jimmy A Volmink2, Freedom Gumedze3, Gary Maartens4, Akinyemi Aje5, Baby M Thomas6, Kandathil M Thomas6, Abolade A Awotedu6, Bongani Thembela7, Phindile Mntla8, Frans Maritz9, Kathleen Ngu Blackett10, Duquesne C Nkouonlack10, Vanessa C Burch11, Kevin Rebe11, Andy Parish12, Karen Sliwa13, Brian Z Vezi14, Nowshad Alam15, Basil G Brown16, Trevor Gould17, Tim Visser18, Muki S Shey19, Nombulelo P Magula20 and Patrick J Commerford1

Author Affiliations

1 The Cardiac Clinic, Department of Medicine, University of Cape Town, E25 Groote Schuur Hospital, Observatory 7925, South Africa

2 Primary Health Care Directorate, University of Cape Town, Cape Town, South Africa

3 Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa

4 Division of Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa

5 Department of Cardiology, University College Hospital, Ibadan, Nigeria

6 Department of Medicine, Nelson Mandela Academic Hospital and Walter Sisulu University, Mthatha, South Africa

7 Department of Medicine, Prince Mshiyeni Hospital, Durban, South Africa

8 Department of Cardiology, MEDUNSA, Pretoria, South Africa

9 Department of Internal Medicine, Karl Bremer Hospital, Bellville, South Africa

10 Faculty of Medicine and Biomedical Sciences, University of Yaoundé I and Centre Hospitalier et Universitaire, Yaoundé, Cameroon

11 Department of Medicine, GF Jooste Hospital, Cape Town, South Africa

12 Cecilia Makiwane Hospital, East London, South Africa

13 Department of Cardiology, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Soweto, South Africa

14 Subdepartment of Cardiology, Inkosi Albert Luthuli Central Hospital and University of KwaZulu Natal, Durban, South Africa

15 Livingstone's Hospital, Port Elizabeth, South Africa

16 Provincial Hospital, Port Elizabeth, South Africa

17 Department of Medicine, George Hospital, George, South Africa

18 Eersterivier Hospital, Cape Town, South Africa

19 Mycobacterial Immunology Group, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa

20 Subdepartment of Infectious Diseases, Department of Medicine, King Edward VIII Hospital and University of KwaZulu Natal, Durban, South Africa

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BMC Infectious Diseases 2006, 6:2  doi:10.1186/1471-2334-6-2

Published: 6 January 2006

Abstract

Background

The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa.

Methods

Consecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status.

Results

A total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs.

Conclusion

Patients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.