대한흉부영상의학회 Weekly Chest Cases

Case No : 1290 Date 2022-07-11

Courtesy of Da Som Kim, Ji-yeon Han, Seok Jin Choi / Inje University Busan Paik Hospital
Age/Sex 77 / M
Chief ComplaintDyspnea, both leg edema for 6 months

Figure 1
Figure 2
Figure 3
Figure 4

Diagnosis With Brief Discussion

Diagnosis: Tuberculous pericarditis
Radiologic Findings: Fig 1-2. Chest CT scans show diffuse and irregular low-attenuated pericardial thickening, and bilateral pleural effusion.
Fig 3. MR scans reveal irregular pericardial thickening with T1-high and T2-high signal intensity. The lesion shows diffusion restriction and multiloculated appearance with peripheral enhancement.
Fig 4. PET/CT shows diffuse lobulated hot uptake along pericardium (SUV 8.8).
Brief Review: In the present case, pericardium excision was performed. The diagnosis of the intraoperative frozen section was necrotizing granulomatous and the final pathologic report was revealed as necrosis with chronic inflammation and fibrosis. The Diagnosis of tuberculous pericarditis was confirmed by positive TB-PCR.
Tuberculosis involving the heart is rare, accounting for only 0.5% of cases of extrapulmonary tuberculosis. The main presenting finding is pericardial involvement, particularly in immunocompromised patients. A high prevalence of tuberculous-related pericarditis is reported in developing countries, and this disease accounts for up to 90% of cases when the disease is associated with human immunodeficiency virus infection.
Mycobacterium tuberculosis (Mtb) bacilli can enter the pericardium by retrograde lymphatic spread, hematogenous dissemination, or, uncommonly, by direct contiguous spread from adjacent infected structures such as the lungs, pleura, and spine.
The primary sign of tuberculous pericarditis is the pericardial thickening of more than 3 mm in adults; this finding is seen in the majority of cases. CT demonstrates a thickened, irregular pericardium, frequently with associated mediastinal lymphadenopathy. Most patients have distention of the inferior vena cava to a diameter exceeding 3 cm; pleural effusions, typically bilateral; and deformities of the intraventricular septum.
Pericardial abscess is a walled-off collection of pus within the pericardial space and most frequently occurs secondary to tuberculous pericarditis. The presence of predominant involvement of the right atrioventricular groove with features suggesting localized pericardial tamponade should make one suspect this entity. MRI has been shown to be more sensitive for the detection of small effusions, especially loculated effusions. The presence of high signal intensity on the T1-weighted images does strongly suggest a high proteinaceous content, indicating an exudate. The thickened pericardium shows a signal intensity equal to the myocardium on T1-weighted images, while low signal intensity lesions may be observed on the inner surface of the thickening pericardium, which reflects ferromagnetic elements after hemorrhage as well as fibrosis of the pericardium. Linear low signals depicted in the pericardial sac on T2 weighted probably represent strands of granulation tissue in past reports. Uniform tramline-like enhancement at the site of the fibrous hypertrophic parietal and visceral pericardia was reported. Although CT depicts either pericardial thickening or fluid collection, MRI may be helpful for evaluating the pericardial abscess and the diagnosis of tuberculous pericarditis.
References: 1. Burrill, Joshua, et al. "Tuberculosis: a radiologic review." Radiographics 27.5 (2007): 1255-1273.Current Cardiology Reports (2020) 22: 2
2. Jurado, Leonardo F., et al. "Tuberculous pericarditis." Biom
Keywords: Tuberculous pericarditis,

No. of Applicants : 88

▶ Correct Answer : 24/88, 27.3%

- Wakayama Red Cross Hospital , Japan TOMOAKI OTANI
- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- CHCB , France LE GUEN RAPHAEL
- Ajou University Hospital , Korea (South) KYUNGMIN LEE
- , Turkey GOKHAN ARSLAN
- Scans world , India PHILSON JOSEPH MUKKADA
- Samsung Medical Center , Korea (South) JUHYUN KIM
- Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
- Osaka University , Japan AKINORI HATA
- Ajou University Hospital , Korea (South) MINJI KIM
- Sri sathya sai institute of higher medical sciences , India SK ISMAIL
- Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
- Kyoto University Hospital , Japan YASUHISA KURATA
- , Korea (South) YEONG UK HWANG
- Mallinckrodt Institute of Radiology , United States NAGANATHAN MANI
- Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
- , Qatar NABIL SHERIF MAHMOOD
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Kyoto University Hospital , Japan SATOSHI IKEDA
- Paras hospital, Panchkula , India SHALEEN RANA
- Seoul National University Bundang Hospital , Korea (South) YOONAH DO
- Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
- the first affiliatited hospital of nanjing medical univercity , China HAI XU

▶ Correct Answer as Differential Diagnosis : 28/88, 31.8%

- , Japan HIROAKI ARAKAWA
- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- Showa General Hospital , Japan MASAFUMI KAIUME
- Ajou University Hospital , Korea (South) SUNG HYUN AN
- Kyoto University Hospital , Japan YUSUKE UTSUNOMIYA
- National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
- Tiger Gate Hospital , Japan SHIN-ICHI CHO
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Other , Korea (South) SEONGSU KANG
- Ajou University Hospital , Korea (South) HAEIN LEE
- Shimada General Medical Center , Japan HAYATO NOZAWA
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Ajou University Hospital , Korea (South) JAYOUNG MOON
- Gifu University Hospital , Japan Yo Kaneko
- Ajou University Hospital , Korea (South) YOU NA KIM
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
- Chungbuk National University Hospital , Korea (South) MIHYEON PARK
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Other , Korea (South) SEONG WON JANG
- Other , Korea (South) KYU-CHONG LEE
- Nishida Hospital , Japan SHOJI OKUDA
- Toranomon Hospital , Japan KAORU SUMIDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
- , Japan YUMI MAEHARA
- , Japan YUKI HAYASHI
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Semi-Correct Answer : 3/88, 3.4%

- , Korea (South) MINJI KIM
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY

대한흉부영상의학회 Korean Society of Thoracic Radiology

Cases by Disease Category

Case No : 1290 Date 2022-07-11

Discussion

No. of Applicants : 88