Abstract
Background: Tuberculous pericarditis is a rare manifestation of tuberculosis in developed countries and poses a significant diagnostic challenge due to its nonspecific clinical presentation. Immunocompromised individuals, particularly those receiving tumor necrosis factor-alpha (TNF-α) inhibitors, are at substantially increased risk of developing tuberculosis. Therefore, screening for tuberculosis infection and active disease is essential prior to initiating biological therapy.
Case Report: A woman in her 20s with ankylosing spondylitis had negative tuberculosis screening prior to starting adalimumab therapy. After approximately one year of treatment, she presented with a dry cough, exertional dyspnea, and fever. Imaging revealed diffuse miliary pulmonary nodules, focal consolidations, hilar and mediastinal lymphadenopathy, and a large pericardial effusion. Transthoracic echocardiography confirmed cardiac tamponade. Echocardiography-guided pericardiocentesis was performed, and pericardial fluid was submitted for microbiological analysis. Disseminated tuberculosis with pericardial involvement was microbiologically confirmed by positive Xpert MTB/RIF and mycobacterial culture results from pericardial fluid, sputum, and stool specimens. The patient was transferred to a specialist unit and started on first-line antituberculous therapy combined with corticosteroids to prevent constrictive pericarditis. She demonstrated progressive clinical and radiological improvement, including complete resolution of the pericardial effusion and negative follow-up sputum microscopy, and was discharged to complete therapy with outpatient follow-up.
Conclusions: This case demonstrates that severe extrapulmonary tuberculosis, including tuberculous pericarditis complicated by life-threatening cardiac tamponade, can occur in patients receiving TNF-α inhibitors despite negative pre-treatment screening. It highlights the limitations of baseline tuberculosis testing, underscores the need for sustained clinical vigilance during biological therapy, and illustrates successful management with first-line antituberculous therapy combined with corticosteroids.
Keywords
Cardiac tamponade, Tuberculous pericarditis, Adalimumab, Case report