title: Tuberculous Pericarditis is Multibacillary and Bacterial Burden Drives High Mortality.
abstract: BACKGROUND
  Tuberculous pericarditis is considered to be a paucibacillary process; the large pericardial fluid accumulation is attributed to an inflammatory response to tuberculoproteins. Mortality rates are high. We investigated the role of clinical and microbial factors predictive of tuberculous pericarditis mortality using the artificial intelligence algorithm termed classification and regression tree (CART) analysis.
  
  
  METHODS
  Patients were prospectively enrolled and followed in the Investigation of the Management of Pericarditis (IMPI) registry. Clinical and laboratory data of 70 patients with confirmed tuberculous pericarditis, including time-to-positive (TTP) cultures from pericardial fluid, were extracted and analyzed for mortality outcomes using CART. TTP was translated to log10 colony forming units (CFUs) per mL, and compared to that obtained from sputum in some of our patients.
  
  
  RESULTS
  Seventy patients with proven tuberculous pericarditis were enrolled. The median patient age was 35 (range: 20-71) years. The median, follow up was for 11.97 (range: 0·03-74.73) months. The median TTP for pericardial fluid cultures was 22 (range: 4-58) days or 3.91(range: 0·5-8·96) log10CFU/mL, which overlapped with the range of 3.24-7.42 log10CFU/mL encountered in sputum, a multi-bacillary disease. The overall mortality rate was 1.43 per 100 person-months. CART identified follow-up duration of 5·23 months on directly observed therapy, a CD4 + count of ≤ 199.5/mL, and TTP ≤ 14 days (bacillary load ≥ 5.53 log10 CFU/mL) as predictive of mortality. TTP interacted with follow-up duration in a non-linear fashion.
  
  
  CONCLUSIONS
  Patients with culture confirmed tuberculous pericarditis have a high bacillary burden, and this bacterial burden drives mortality. Thus proven tuberculosis pericarditis is not a paucibacillary disease. Moreover, the severe immunosuppression suggests limited inflammation. There is a need for the design of a highly bactericidal regimen for this condition.
authors: Center for Infectious Diseases Research & Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA.
authors: Jotam G
authors: JG
authors: Pasipanodya
authors: The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors: Mwenya
authors: M
authors: Mubanga
authors: The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors: Mpiko
authors: M
authors: Ntsekhe
authors: The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors: Shaheen
authors: S
authors: Pandie
authors: National Health Laboratory Services (Tshwane Academic Division), Department of Medical Microbiology, University of Pretoria, South Africa.
authors: Beki T
authors: BT
authors: Magazi
authors: Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa.
authors: Freedom
authors: F
authors: Gumedze
authors: School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors: Landon
authors: L
authors: Myer
authors: The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Center for Infectious Diseases Research & Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA.
authors: Tawanda
authors: T
authors: Gumbo
authors: The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors: Bongani M
authors: BM
authors: Mayosi
mesh_terms: D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D001185:Artificial Intelligence; D058491:Bacterial Load; D018791:CD4 Lymphocyte Count; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis; D010490:Pericardial Effusion / Q000382:microbiology; D010495:Pericarditis, Tuberculous / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology* / Q000401:mortality*; D012042:Registries; D013183:Sputum / Q000382:microbiology; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents
keywords: Age; Bacterial burden; CD4 + counts; HIV; Therapy failure