IJCS | Volume 33, Nº3, May / June 2020

297 Trêpa et al. Acute pericarditis on imunosupressive drugs Int J Cardiovasc Sci. 2020; 33(3):295-298 Case Report alone, we decided to assume the presumptive diagnostis of tuberculous pericarditis. We maintained the Anti- TNF α discontinued and started corticosteroids and anti-TB drugs (isoniazid and rifampicin for 6 months and pyrazinamide and ethambutol for 2 months). The patient showed progressive improvement. Control echocardiography at one and eight months after ending TB-treatment revealed complete resolution of effusion and of constriction criteria. Discussion As the number of immunosuppressed patients grows, the diagnostic and therapeutic dilemma reported here will probably increase since these patients are particularly complex tomanage. Viral etiology of pericarditis remains the most frequent one, but it is mandatory to consider not only the associationwith the underlying autoimmune disease or with immunomodulation therapy but also the risk of opportunistic infections. Pericarditis was first described as an extra-intestinal manifestation of irritable bowel disease (IBD) in 1967. 1 It’s the most frequently reported cardiac complication and has various presentations, since self-limited forms until severe perimyocarditis and cardiac tamponade, 2-6 The most accepted pathophysiological mechanism is based on the pericardial aggression due to systemic inflammation. An Italian study 3 reported a possible relationship between pericardial effusion and IBD flares. The development of pericarditis does not seem to be related to disease chronicity and has been described both independently and in association with IBD flares. 5 There are also reports of pericarditis as a complication of immunomodulatory therapy itself, such as associated with 5-ASA, azathioprine and anti-TNF α drugs. Accepted explanations include lupus-like reactions, type 3 hypersensitivity and pro-inflammatory effect of some drugs in serous membranes. 6-8 Usually, there is a clear temporal relation with the initiation of drug use, with improvement after its discontinuation and an increase in anti-histone antibodies. In our case, only the antibodywas elevatedmaking it hard to establish a causal relationship. The approach would be to discontinue the offending drug and initiate corticosteroid therapy. The presumptive diagnosis of TB was assumed after a multidisciplinary meeting and careful consideration. TB prevalence is still high in the urban region where our patient lives. There is a known correlation between anti-TNF α and TB reactivation that justifies mandatory screening before starting treatment. In case of TB pericarditis, a definitive diagnosis is notoriously difficult due to the low yield of cultures and biopsies, and usually a presumptive or exclusion diagnosis is made. The progression to constrictive pericarditis is a potentially serious complication. Without a targeted therapy, up to 50% of patients with effusive-constrictive physiology might progress to constriction in six months. 9 Several studies reinforce the need to consider TB pericarditis in patients at increased risk for TB development with non- benign evolution. In the absence of Koch bacillus isolation from the pericardial fluid or tissue, TB pericarditis is considered likely if the bacillus is isolated from sources and/or if there is a favorable response (based on symptoms and echo) to anti TB-drugs. 10 In patients taking anti-TNF α drugs, there is a particularly increased risk of TB, frequently extra-pulmonary. The impossibility of performing pericardiocentesis was a limiting factor in our diagnostic approach. However, in the absence of other strong diagnostic hypotheses, and given the treatment with anti-TNF α , the high TB prevalence, the angioCT and echo findings, and the possibility of irreversible adverse outcome if untreated, we assumed the presumptive diagnosis of TB pericarditis. The good response to treatment favored our decision. This case report portraits thedifficulties in thediagnosis of these patients, but also provides possible therapeutic strategies. In the absence of strong recommendations for such complex cases, we trust in experience and multidisciplinary discussion. These cases should be managed with specific strategies defined individually. Author contributions Conception and design of the research: TrêpaM, Neves I, Dias V. Acquisition of data: Trêpa M, Neves I, Dias V. Analysis and interpretation of the data: TrêpaM, Salgado M, Carvalheiras G. Writing of the manuscript: Trêpa M. Critical revision of themanuscript for intellectual content: Trêpa M, Neves I, Salgado M, Carvalheiras G, Dias V. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study.