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.
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.


CONCLUSIONS
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.
Mayosi
Bongani M
BM
The Cardiac Clinic, Department of Medicine, University of Cape Town, E25 Groote Schuur Hospital, Observatory 7925, South Africa. bmayosi@uctgsh1.uct.ac.za
Wiysonge
Charles Shey
CS
Ntsekhe
Mpiko
M
Volmink
Jimmy A
JA
Gumedze
Freedom
F
Maartens
Gary
G
Aje
Akinyemi
A
Thomas
Baby M
BM
Thomas
Kandathil M
KM
Awotedu
Abolade A
AA
Thembela
Bongani
B
Mntla
Phindile
P
Maritz
Frans
F
Blackett
Kathleen Ngu
KN
Nkouonlack
Duquesne C
DC
Burch
Vanessa C
VC
Rebe
Kevin
K
Parish
Andy
A
Sliwa
Karen
K
Vezi
Brian Z
BZ
Alam
Nowshad
N
Brown
Basil G
BG
Gould
Trevor
T
Visser
Tim
T
Shey
Muki S
MS
Magula
Nombulelo P
NP
Commerford
Patrick J
PJ
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D002163:Cameroon / Q000453:epidemiology; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009549:Nigeria / Q000453:epidemiology; D016017:Odds Ratio; D010495:Pericarditis, Tuberculous / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology*; D011446:Prospective Studies; D012042:Registries; D013019:South Africa / Q000453:epidemiology
D000305:Adrenal Cortex Hormones; D019380:Anti-HIV Agents; D000995:Antitubercular Agents