Tuberculous Pericarditis and AIDS

Successful use of NMV in non-obstructive conditions'·' led us to consider similar ventilatory support in this case. Following a repeat study with conventional nasal CPAP (confirming an apnea index of 65/hr), a pressure respirator was substituted for the blower motor and connected to the nasal mask via a conventional circuit. It was set to respond to the patient's nasal inspiratory effort and to a comfortable pressure limit (in this case 20 em H 20). The accompanying figure shows the complete resolution of obstructive apnea. We wish to suggest this method of treating severe obstructive sleep apnea ifconventional approaches fail, and note that use of the ubiquitous pressure ventilator could be considered in other instances where NMV may be indicated. A. J Wdliams, M.B., M.C.R.P., and S. Santiago, M.D., University of California, wsAngeles

mm3 and the OKT/OKT. index was 0.4. The patient died with AIDS dementia complex 12 months after tuberculous pericarditis was diagnosed. CAsE2 A 23-year-old male heroin addict was admitted with fever and chest pain of three weeks duration. On physical examination the patient appeared ill, temperature 39"C, pulse rate 120 bpm, and BP 110160 mmHg. Although a pericardia! rub was found, signs of tamponade were not evident. Laboratory data showed hemoglobin 130 WL and WBC 9. 7 X 10"/L. HIV antibodies were positives by ELISA assay and immunofluorescence; HIV antigen was negative. T, helper lymphocytes were 3531mm3 and OKT/OKT, index 0.9. Chest x-ray film showed cardiomegaly; lung fields were clear and pericardia! fluid was evident by echocardiography. A pericardiocentesis removed 800 ml of yellow fluid which grew Mycobacterium tuberculosis. The patient was treated with rifampin, ethambutol, isoniazid and prednisone with good response, and remains asymptomatic 14 months later.

REFERENCES

1 NHLBI Workshop summary. Respiratory disorders in sleep. Am Rev Respir Dis 1987; 136:755-61 2 Popper R, Leidinger J, Williams AJ. Bronchoscopic observations of the velopharyngeal sphincter during treatment of obstructive sleep apnea with nasal CPAP. West J Med 1986; 144:83-85 3 Kerby GR, Mayer LS, Pingleton SK. Nocturnal positive pressure ventilation via nasal mask. Am Rev Respir Dis 1987; 135:738-40 4 Carroll N, Branthwaite MA. Domicilliary positive pressure ventilation, using a nasal mask, for nocturnal hypoventilation. Thorax 1988; 43:723

Tuberculous

Pericarditis

DISCUSSION

Although tuberculous pericarditis is rarely seen today,• its frequency is probably rising with AIDS. 2•3 This form of pericarditis is characterized by its early cardiac arrhythmias and tendency to tamponade. Removal of pericardia! fluid by pericardiocentesis or pericardiectomy is an important therapeutic maneuver in this process, which still presents a mortality of 40 percent.' The positivity of HIV antigen in the first case may be a sign of poor prognosis and progression of AIDS, as previously described.• The tuberculous pericarditis should be suspected in patients at risk for VIH infection with fever and symptoms of pericarditis, or hemodynamic deterioration.

and AIDS

julio de Miguel M.D.; jose D. ftdnrira M.D.; VICente Campos, M.D.; Agustfn Perez Gomez M.D., and jose A. wrenzo Porto. M.D, juan Canalejo Hospital, lA Corona, Spain

7b the Editor:

Extrapulmonary tuberculosis and acquired immunodeficiency syndrome {AIDS) have been frequently associated since the initial description of syndrome. Actually extrapulmonary tuberculosis is considered an opportunistic infection in AIDS, 1 and most tuberculous infections in these patients are ganglionary or disseminated. Tuberculous pericarditis has been rarely associated to AIDS.., and it has always been the initial event in both conditions. We describe two patients with tuberculous pericarditis as the first manifestation of AIDS. CASE REPORTS

CASE 1 A 27-year-old homosexual heroin-addict man was admitted to hospital with fever, astenia, chest pain and dyspnea of four weeks duration. He denied previous history of tuberculous infection. His temperature was 38.5"C, BP110170 mmHg and pulse rate 100 bpm. A pericardia! rub was heard and chest x-ray showed cardiomegaly without lung abnormalities. Hemoglobin was 112 !VL, leukocytes 7.4X 10"/L, ESR 75 mm, and PPD skin test results were negative. Antibodies to human immunodeficiem:y virus (HIV) were detected by ELISA test and immunofluorescence. A determination of HIV antigen by ELISA (HTLV-III Antigen-EIA, Abbott) was positive. Echocardiographic examination confirmed important pericardia! effusion, and the day after admission signs of pericardia! tamponade were observed. A pericardiectomy was performed and 1,500 ml of yellow fluid was removed, from which Mycobacterium tuberculosis was cultured. Pericardia! biopsy showed necrotizing granulomata inflammation with acid-fast micrrganisms. Treatment with rifampin, isoniazid, ethambutol and prednisone was started; the patient was discharged 15 days after admission to hospital, in good condition. He was readmitted eight months later with fever, dyspnea and reticulonodular infiltrates on chest x-ray film. Pneumocystis carinii pneumonia was diagnosed. T, helper lymphocytes were 78/

REFERENCES

1 Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987; 36:1s-15s 2 DCruz lA, Sengupta EE, Abrahams C, Reddy HK, Turlapati RV. Cardiac involvement, including tuberculous pericardia! effusion, complicating acquired immune deficiency syndrome. Am Heart J 1986; 112:1100-02 3 Dalli E, Quesada A, Juan G, Navarro R, Paya R, Tormo V. Tuberculous pericarditis as the first manifestation of acquired immunodeficiency syndrome. Am Heart J 1987; 114:905-06 4 Ortbals DW, Avioli LV. Tuberculous pericarditis. Arch Intern Med 1979; 139:231-34 5 Wittek AE, Phelan MA, Wells MA, et al. Detection of human immunodeficiency virus core protein in plasma by enzyme immunoassay. Ann Intern Med 1987; 107:286-92

Caffeine and Methylxanthines To the Editor: Many Americans imbibe calfeine-<.~mtaining beverages such a~ tea and (.~>las. Theophylline and other methylxanthines are often used in therapy. I wish to JK>int out that methylxanthines may interfere with the action of dipyridamole, a frequently-used antithmmiK>tic agent. Dipyridamole inhibits cellular uptake of adenosine, a ubiquitous purine nucleoside. raising hi1K>d adenosine levels. 1 Adenosine is a L~>ffee,

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