Pericardial effusion: Clinical and analytical parameters clues

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International Journal of Cardiology 108 (2006) 404 – 405 www.elsevier.com/locate/ijcard

Letter to the Editor

Pericardial effusion: Clinical and analytical parameters clues Gustavo Iglesias Cubero*, Jose´ Rubin, Maria Martı´n, Juan Rondan, Eugenio Simarro Servicio de Cardiologı´a, Hospital Universitario Central de Asturias, Julia´n Claveria sn, 33006 Oviedo, Spain Received 5 March 2005; accepted 12 March 2005 Available online 3 May 2005

Abstract Prospectively, clinical and biochemical data of 83 patients with a diagnosis of pericardial effusion were studied. The etiologies were as follows: Idiopathic: 42 cases (50%); Tuberculous: 18 cases (22%); Neoplastic: 14 cases (17%); Other: 9 cases (11%) with a miscellaneous etiology. Sedimentation rate resulted significantly higher in Tuberculous group (67 – 102), p < 0.05. The highest values of adenosine deaminase in pericardial fluid were observed in Tuberculous group (110 U/l), p < 0.001. Diagnosis of tuberculosis was established by culture of the bacillus in sputum in 8 cases and by pericardial biopsy in 11 patients. Analysis of the pericardial fluid leads to diagnosis in 25 cases (30%). The pericardial biopsy resulted as the most reliable method for the diagnosis of tuberculous pericarditis. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Pericardial effusion; Adenosine deaminase; Tuberculosis; Neoplasm; Idiopathic

Prospectively, between 1980 and 1995, the pericardial fluids of 83 patients (64% males, 36% females) with an average age of 59 T 2 years and that required a pericardiocentesis or surgical drainage, were derived from our tertiary hospital (Asturias, Spain). The reason for drainage was tamponade in 53 cases (62%), the others being chronic or recurrent cases. An established protocol was accomplished in all cases. Clinical data of patients were collected. For symptoms, the criteria taken into account were thoracic pain, dyspnoea and general syndrome. Pericardial fluids were processed for microbiological culture (aerobic and anaerobic organisms), biochemical (glucose, LDH, proteins, adenosine deaminase) and cytological studies. Study of bacillus tuberculosis (BT) was made by histology or culture in sputum, pericardium and pericardial fluid. For the determination of adenosine deaminase (ADA), the Giusti Method was used [1]. Statistical analysis was carried out using a RSIGMA

* Corresponding author. Cardiology Department, Hospital Central de Asturias, Julia´n Claverı´a s/n, 33006 Oviedo, Spain. Fax: +34 985274688. E-mail address: [email protected] (G.I. Cubero). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.03.037

program. Comparative analysis was carried out using the Student–Newman-Pick test for quantitative variables, and the X 2 for qualitative variables. The Fisher test was used for values lower than 5. Pericardial effusions were classified as follows: Idiopathic (I). Forty-two effusions without any underlying etiology. Tuberculous (TBC). Eighteen cases. Neoplastic (N). Fourteen effusions (5 lung cancer, 3 breast cancer, 1 liposarcoma and 5 adenocarcinoma of unknown origin). Other (O). These were: 1 purulent pericarditis (Bacteroids spp), 2 constrictive pericarditis, 4 radiation pericarditis, 1 traumatic and 1 case post-surgical pericarditis. Our study shows a greater number of idiopathic effusions than that referred previously [2]. Traditionally, bloody fluid has been considered as a bad prognosis [3]. In our study bloody effusions were either neoplastics or idiopathics. The tuberculin skin test that was carried out in 77% of the patients, showed a sensitivity of 75% with specificity of 68%, predictive positive value of 47% and a predictive negative value of 88%, thus it could be used to reject a tuberculosis origin.

G.I. Cubero et al. / International Journal of Cardiology 108 (2006) 404 – 405

In the diagnosis of TBC, a 1st hour SR > 50 had sensitivity of 83%, specificity of 63%, positive predictive value of 38% and negative predictive value of 93%. The ADA values of TBC group were the highest (> 60 U/ l, p < 0.001). An ADA value > 60 U/l showed a sensitivity of 100%, specificity of 90%, predictive positive value of 90% with predictive negative value of 100% for the diagnosis of tuberculosis. A diagnosis of tuberculosis was made by culture demonstration of BT in sputum in 8 cases, by pericardial biopsy in 11 cases and from pericardial fluid in 13 cases. So, analysis of pericardial fluid that also diagnosed 11 cases of neoplastic effusions and 1 case of purulent effusion, was able to establish the etiology in 25 patients (30%). The cytological study of fluid diagnosed neoplasm in 11 of the 14 neoplastic effusions.

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Finally, from a total of 53 patients with tamponade, the analysis of the fluid leads to the etiology in 15 cases (28%). In the remaining 30 cases the diagnosis was established in 10 cases (33%).

References [1] Giusti G. Adenosine deaminase. In: Bergmeyer HV, editor. Methods of enzymatic analysis. New York’ Academic Press Inc; 1974. p. 1092 – 9. [2] Permanyer-Miralda G, Sagrista´-Sauleda J, Soler Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623 – 30. [3] Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s. Chest 1999;116:1564 – 9.

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