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cardio.cardiac-tamponade.tb-pericarditis.v1

Cardiac tamponade — tuberculous pericarditis

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to tuberculous pericarditis (Mycobacterium tuberculosis infection of pericardium causing exudative effusion + fibrinous pericarditis + caseating granulomas). High burden in HIV+ patients in endemic regions (sub-Saharan Africa, India, Southeast Asia). Inherits drainage + bridge regimen from parent via routing; specializes for TB-specific patterns: pericardial fluid ADA >40 U/L (sensitivity 88%, specificity 83% per Burgess Chest 2002 + Reuter EHJ 2006), IGRA on fluid, Xpert MTB/RIF on fluid, AFB stain + culture, lymphocytic exudate; pericardial biopsy GOLD STANDARD with culture + histology + Xpert; 4-drug RIPE regimen × 6 mo (rifampin + INH + PZA + ethambutol intensive 2 mo + RI continuation 4 mo) per WHO 2024; ADJUNCTIVE prednisolone 60 mg PO daily × 4 wk taper × 6 wk per IMPI trial (Mayosi NEJM 2014 PMID 25199187) ONLY in HIV-NEGATIVE — reduced constriction risk; AVOID steroids in HIV+ per IMPI subgroup (Kaposi sarcoma risk); universal HIV testing + ART optimization with IRIS-aware timing per WHO HIV/TB; pericardiectomy for chronic constrictive pericarditis (~25% develop) per ESC 2015 Class IIa. Severity triggers cover HIV co-infection management, drug-induced hepatitis, MDR-TB resistance, constrictive pericarditis development at 6 mo, IRIS paradoxical worsening. Multidisciplinary care: ID + cardiology + pulmonology + HIV care + public health TB program + cardiothoracic surgery; DOT (directly observed therapy) enrollment essential; contact tracing required. Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (TB-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (5)

  • symptom
    Subacute (days-weeks) dyspnea + fever + weight loss + night sweats + Beck triad in patient with TB risk factors (endemic region, HIV+, prior TB, healthcare worker) → tuberculous tamponade (ESC 2015 §Tuberculous Pericarditis; Mayosi Heart 2017)
    subacute_dyspnea_with_tb_constitutional_symptoms
  • imaging
    Echo: pericardial effusion (often large >2 cm) with fibrin strands or septations + RV diastolic collapse + IVC plethora in patient with TB risk factors (ESC 2015)
    echo_large_effusion_with_fibrin_strands
  • history
    HIV+ patient (especially sub-Saharan Africa, India) presenting with new pericardial effusion — TB pericarditis is leading cause of pericardial disease in this population (Mayosi NEJM 2014 IMPI PMID 25199187; Sliwa)
    hiv_positive_with_pericardial_effusion
  • symptom
    Known pulmonary TB or chest CT with mediastinal lymphadenopathy + cavitary disease + new pericardial effusion (ESC 2015; WHO 2024)
    pulmonary_tb_with_new_pericardial_effusion
  • history
    Pericarditis not responding to colchicine + NSAIDs after 2 wk in TB-risk patient → consider TB etiology (ESC 2015)
    failed_response_to_anti_inflammatory_pericarditis_treatment

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Age modifies HIV co-infection probability + drug interaction profile + steroid risk-benefit (WHO TB 2024)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad; pulsus paradoxus measurement (Spodick Circulation 2003)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade physiology (ESC 2015)
  • temperaturerequired
    vital • used at INITIAL_WORKUP
    Fever is a key constitutional symptom of TB; pattern + height inform clinical suspicion (ESC 2015 §Tuberculous Pericarditis; Mayosi Heart 2017)
  • echorequired
    imaging • used at INITIAL_WORKUP
    Definitive bedside dx — chamber collapse, IVC, swinging heart; fibrin strands and loculations characteristic of TB etiology (ESC 2015 Class I)
  • hiv_status_and_cd4_countrequired
    history • used at CONTEXT
    Universal HIV testing in suspected TB pericarditis (WHO 2024); CD4 count drives steroid decision (IMPI subgroup PMID 25199187 — KS risk in HIV+ on steroids); also drives ART timing per WHO IRIS guidance
  • tb_exposure_and_risk_factorsrequired
    history • used at CONTEXT
    Endemic region, prior TB, healthcare worker, immunocompromise, contacts — drives pre-test probability (WHO 2024)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline for ethambutol + RIPE drug dose-adjustment + nephrotoxicity surveillance (WHO TB 2024)
  • altrequired
    lab • used at INITIAL_WORKUP
    Baseline for RIPE-induced hepatitis surveillance — INH/RIF/PZA all hepatotoxic (WHO TB 2024 — discontinue if ALT >5x ULN or symptomatic)
  • chest_imaging_for_pulmonary_tbrequired
    imaging • used at INITIAL_WORKUP
    CXR or chest CT for active pulmonary TB (cavitation, infiltrates, mediastinal lymphadenopathy); positive findings strengthen TB pericarditis dx + indicate isolation (WHO 2024)

12-phase flow (9)

  1. 1FRAME
    Tuberculous tamponade — pericardiocentesis for diagnosis + tamponade relief; 4-drug RIPE anti-TB therapy is the curative pathway; adjunctive steroids only in HIV-NEGATIVE per IMPI; ~25% develop constrictive pericarditis requiring pericardiectomy (ESC 2015; Mayosi NEJM 2014 PMID 25199187)
    inputs: sbp
    advance: TB-context tamponade physiology suspected
  2. 2ENTRY
    Recognize subacute presentation with constitutional TB symptoms; rule in TB etiology vs viral vs autoimmune vs malignant; HIV testing universal (Mayosi Heart 2017; WHO 2024)
    inputs: age
    advance: TB-risk context confirmed + universal HIV testing initiated
  3. 3CONTEXT
    Document HIV status + CD4 count, TB exposure, prior TB treatment, drug-resistance history, contacts requiring screening, comorbidities affecting RIPE tolerance (WHO 2024)
    inputs: hiv_status_and_cd4_count, tb_exposure_and_risk_factors
    advance: TB-context risk factors + HIV status fully captured
  4. 4RED_FLAGS
    Tamponade obstructive shock physiology + concurrent disseminated TB (military, meningeal) screen + IRIS risk if ART-naive HIV+ (ESC 2015; WHO 2024)
    inputs: sbp, hr
    advance: shock recognized + disseminated TB screen + IRIS risk stratified
  5. 5INITIAL_WORKUP
    STAT echo, ECG, CXR, troponin, BMP, CBC with diff (lymphocytic predominance suggestive), HIV test, IGRA on serum, CRP, ESR, LDH, baseline ALT/Cr (WHO 2024; ESC 2015)
    inputs: echo, creatinine, alt, chest_imaging_for_pulmonary_tb, temperature
    actions: panel.cardiac, panel.renal, panel.cbc
    advance: echo confirms tamponade physiology + TB workup initiated
  6. 6DIFFERENTIAL
    Pericardial fluid analysis: ADA >40 U/L (sensitivity 88%, specificity 83%), IGRA on fluid, Xpert MTB/RIF on fluid, AFB stain + culture, cell count (lymphocytic exudate >50% lymphs), glucose (low), LDH (high), protein (high); pericardial biopsy GOLD STANDARD with culture + histology + Xpert (ESC 2015; Burgess Chest 2002; Reuter EHJ 2006)
    advance: fluid + biopsy specimens sent for full TB workup
  7. 7TREATMENT
    Step 1 echo-guided pericardiocentesis (diagnostic + therapeutic if hemodynamic compromise); Step 2 4-drug RIPE intensive phase × 2 mo (rifampin + isoniazid + pyrazinamide + ethambutol) per WHO 2024; Step 3 RI continuation phase × 4 mo; Step 4 ADJUNCTIVE prednisolone 60 mg PO daily × 4 wk taper × 6 wk per IMPI ONLY in HIV-NEGATIVE (Mayosi NEJM 2014 PMID 25199187 — reduced constriction risk; NO benefit and POSSIBLE HARM in HIV+ from KS); Step 5 ART optimization in HIV+ per WHO IRIS guidance; Step 6 pericardiectomy for chronic constrictive pericarditis (~25%)
    inputs: sbp
    advance: pericardiocentesis performed + RIPE initiated + steroid decision made + ART optimized if HIV+
  8. 8DISPOSITION
    CCU/ICU if hemodynamic compromise; infection control isolation pending sputum AFB results; multidisciplinary care: cardiology + ID + pulmonology + HIV care if applicable + public health TB program (WHO 2024)
    advance: multidisciplinary disposition confirmed + isolation status determined
  9. 9MONITORING
    Re-accumulation surveillance (echo q24-48h initially then weekly then per follow-up); RIPE drug toxicity monitoring (LFTs q2-4 wk for first 2 mo, visual acuity for ethambutol, hyperuricemia for PZA); CRP trend; constriction surveillance with serial echo + RH cath if symptoms (ESC 2015; WHO 2024)
    actions: panel.pleural
    advance: RIPE response documented + constriction surveillance ongoing