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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 2  |  Page : 116-118
Pericardial cyst due to tuberculosis in an adolescent


Department of Cardiac Anaesthesia, Escorts Heart Institute and Research Centre, New Delhi, India

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   Abstract 

Patient with a mediastinal mass may be diagnosed incidentally or following evaluation for the symptoms due to compressive effects on the adjoining structures. Pericardial cysts account to 6% of mediastinal masses. Echocardiography, computerised tomography and magnetic resonance imaging aid in accurate diagnosis and localization of these cysts. Anaesthesia for patients with these cysts may occasionally turn out to be catastrophic during induction or in postoperative period. Surgery is the preferred choice of treatment in these patients.

Keywords: Pericardial cyst, resection, tubercular

How to cite this article:
Venkatesh B G, Girotra S, Iyer KS, Chakrabarti M, Khurana P, Sen A. Pericardial cyst due to tuberculosis in an adolescent. Ann Card Anaesth 2008;11:116-8

How to cite this URL:
Venkatesh B G, Girotra S, Iyer KS, Chakrabarti M, Khurana P, Sen A. Pericardial cyst due to tuberculosis in an adolescent. Ann Card Anaesth [serial online] 2008 [cited 2019 Dec 12];11:116-8. Available from: http://www.annals.in/text.asp?2008/11/2/116/41580


Pericardial cysts are uncommon benign anomalies. They represent 6% of the mediastinal masses and 33% of the mediastinal cysts. They may be of varied aetiologies such as congenital, lymphomatous, and infective. Patients with such cysts may be asymptomatic or may present with symptoms due to compression effect to the adjacent structures like bronchus, oesophagus, left ventricle (LV), and inferior vena-cava (IVC).


   Case Report Top


A 13-year-old boy weighing 44 kg presented with fever and cough for the past 15 days. He was found to have increased erythrocyte sedimentation rate (ESR 30mm/hr) and strongly positive Mantoux test, while other haematological and biochemical investigations were within normal limits. Echocardiography revealed a small pericardial effusion. Antitubercular therapy (ATT), with Tab. rifampicin 450 mg, Tab. isoniasid 300 mg, and Tab. pyridoxine 10 mg, was commenced and the patient was discharged when he felt better.

A month later, he was re-admitted with loss of appetite, fever, and chest pain. Physical examination revealed pyrexia, and other vital signs were normal. Blood investigations revealed elevated total leucocyte count (14,000 cu.mm), ESR (36 and mm/hr), and deranged liver function tests (total bilirubin - 2.0 mg/dl, SGOT - 86 IU, SGPT - 100 IU). Chest radiograph showed widened mediastinum.

Echocardiography showed no regional wall motion abnormality, good left ventricular (LV) function, and mild pericardial effusion. However, posterior to the LV, there was a well-defined cystic structure with fibrous strands within it. A diagnosis of pericardial cyst or pseudoaneurysm of LV was made [Figure 1].

Computed tomography (CT) angiography revealed a hypodense, localized collection over the diaphragmatic surface of the pericardium overlying the LV near it's apex. The lesion showed an enhancing rim around it in post-contrast scans. Heart appeared normal. No definite evidence of contrast leak was noted. Few calcified lymph nodes were seen in the pre-aortic and hilar regions. Pleural thickening was also noted on the left side. Coronary arteries, aorta, and pulmonary vessels were normal [Figure 2].

Magnetic resonance imaging (MRI) revealed a well-demarcated area of moderate intensity signal in the diaphragmatic aspect of the pericardium below the inferior wall of the LV. The lesion was nearly oval in shape and cystic in nature with the septae within. It was extending from below the apex of LV to a point below the base of LV with high signal intensity. The cyst measured 72 x 40 x 25 mm. Both ventricular cavities appeared normal in size with maintained thickness and contractility [Figure 3].

The patient was scheduled for surgical excision of cyst in view of his symptoms and findings. Informed consent was obtained from parents. All medications including ATT were continued till the morning of surgery. Injection phenergan 25 mg and morphine 5 mg were administered intramuscularly 45 min. prior to arrival in the operating room (OR). General Anaesthesia (GA) with positive pressure ventilation (PPV) was planned. Electrocardiogram, arterial blood pressure, oxygen saturation, central venous pressure, temperature, urine output, and end-tidal carbon dioxide (ETCO 2 ) concentration were recorded.

(ETCO 2 ) was monitored in the OR. GA was induced with intravenous injection thiopentone 125 mg, midazolam 1mg, and fentanyl 200 µg. Trachea was intubated, facilitated by vecuronium. Anaesthesia was maintained with oxygen: air in isoflurane. Vecuronium and fentanyl were intermittently used. Surgery was performed in left lateral position using an incision in the 4th intercostal space in the mid-axillary line. Apex of the LV was accessed and the cyst was drained. The aspirated sample was sent for Gram stain and acid fast bacilli (AFB) examination. There were dense adhesions between cystic wall and the LV with obliteration of tissue planes. Therefore, marsupilisation of cyst was performed and the specimen was sent for histopathological examination. The intra-operative course was uneventful. Chest was closed and the patient was transferred to the recovery room. The patient was ventilated for 3 hours postoperatively. Histopathology examination of the pericardial tissue revealed caseating granuloma.


   Discussion Top


Pericardial cysts may be congenital or inflammatory. Congenital cysts are not only uncommon, but are mostly unilocular and located at the right cardiophrenic angle. Inflammatory cysts can be caused by rheumatic pericarditis, bacterial infection mainly tuberculosis, trauma, and cardiac surgery. [1],[2] Seventy percent of patients with cysts have no associated symptoms and are usually found incidentally during chest X-ray or echocardiography. Symptoms in rest of the patients are chest pain, dyspnoea, cough, fever, and hoarseness of voice. These are usually due to compression of adjacent structures. This was the reason for readmission of this patient. Cardiac tamponade, right ventricular outflow tract obstruction, partial erosion into adjacent structures, and congestive heart failure are some of the complications seen in patients with pericardial cysts. [2]

Echocardiography is routinely performed; however, restricted acoustic window limits the imaging of the entire pericardium. Loculated effusions, especially those in unusual locations can be difficult to diagnose with echocardiography. Transoesophageal echocardiography allows better visualization of pericardium, but is limited by a narrow field of view. CT and MR imaging may provide a larger field of view than echocardiography, thus allowing the examination of the entire chest and detection of associated abnormalities in the mediastinum and lung. They provide excellent delineation and enable precise localization of the pericardial masses. [3],[4]

On CT scan, the pericardial cysts appear as thin-walled, sharply defined, oval homogenous masses. MRI has greater accuracy for differentiation between the pericardium and the myocardium. CT scan depicts calcific areas in cysts, lymph nodes, and pericardium. Hence, both these investigative modalities may help in arriving at a final diagnosis.

Pericardial cyst may not need active intervention; at times, percutaneous drainage and resection may suffice. Effects of mediastinal masses compressing the tracheobronchial tree, great vessels, heart worsen during induction of anaesthesia, surgery, and in the postoperative period.

Induction of anaesthesia with volatile anaesthetic agents and maintaining spontaneous ventilation without the use of a muscle relaxant is ideal. [5] As there was no evidence of airway obstruction or cardiovascular compromise, GA with PPV was preferred.

Resection of the pericardial cyst may be indicated when it is large and causes symptoms. Video-assisted thoracic surgery or thoractomy can be used for resecting the pericardial cysts. [2]


   Conclusion Top


Tubercular pericardial cysts are not only uncommon, but also present with atypical symptoms due to pressure effects on adjacent structures. Apart from echocardiography, CT and MRI enable precise localization of these cysts. Surgery is the preferred procedure.

 
   References Top

1.Sharifi-Mood B, Alavi Naini R, Eazadi M. Cystic tuberculous pericarditis a rare form, J Res Med Sci 2005:10:236-8.  Back to cited text no. 1    
2.Kraev A, Komanapalli CB, Schipper PH, Sukumar MS. Pericardial cyst. Cardiothorac Surg Network 2006;16:1-4.  Back to cited text no. 2    
3.Pepi M, Muratori M. Echocardiography in the diagnosis and management of pericardial disease. J Cardiovasc Med 2006;7:533-44.  Back to cited text no. 3    
4.Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW, Higgins CB. CT and MR imaging of pericardial disease. Radiographics 2003;23:S167-80.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Pullerits J, Holzman R. Anaesthesia for patients with mediastinal masses. Can J Anaesth 1989;36:681-8.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

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Correspondence Address:
B G Venkatesh
Department of Cardiac Anaesthesia, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi - 110 025
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.41580

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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