tuberculosis ( tb ) is responsible for approximately 4% of cases of acute pericarditis , 7% of cases of cardiac tamponade , and , in older studies 6% of instances of constrictive pericarditis . however , in some non - industrialized countries , tuberculosis is a leading cause of pericarditis ( 1 ) . tuberculous pericarditis presents clinically 3 forms , namely , pericardial effusion , constrictive pericarditis , and a combination of effusion and constriction ( 2 ) . echocardiography is very useful for the diagnosis of tuberculous pericardial effusion if the intrapericardial abnormalities , including exudative coating , fibrinous strands , and thickened pericardium are present ( 3 ) . we experienced very unusual case of tb pericarditis presenting as free floating multiple echogenic masses in the pericardial effusion with impending tamponade . on 15 august 2010 , a 14-yr old boy was transferred to our hospital for uncontrolled pneumonia . he developed cough , sputum and malaise 16 days ago , and he had been managed with antibiotics , but his symptoms were aggravated clinically and radiographically . tuberculosis ( tb ) was absent in the family history . on physical examination , he was alert and well - nourished . his vital sign was as follows ; temperature 38 , heart rate 126/min , and respiration rate 24/min . tuberculin purified protein derivative skin test was negative , but sputum showed positive for acid fast bacilli ( afb ) . chest radiograph on admission revealed haziness in right upper and middle lung field ( fig . 1a ) , and high resolution chest computerized tomography showed consolidation , micronodules and branching structures in right lung and lymph node ( ln ) enlargement in both hilum with pericardial effusion ( fig . the afb was identified as m. tuberculosis and was sensitive to all the tb medications except isoniazid in the culture study . predinisolone was given for total 2 months with tapering . in spite of tb medication , he complained persisting fever , aggravating cough and chest pain . chest exam revealed decreased breath sound and chest radiograph revealed aggravated haziness in the right lung with newly appeared consolidation in right lower lung field with a pattern of pericardial effusion ( fig . 1c ) on the 7th day . in the mean while , his hemoglobin decreased gradually from 11.3 g / dl to 9.6 g / dl , but c - reactive protein ( crp ) initially increased from 14.5 mg / dl to 25.4 mg / dl on the 3rd hospital day , and then decreased to 7.6 mg / dl on the 9th day ( fig . 2 ) . echocardiography showed free floating multiple round discoid masses in large amount of pericardial effusion ( fig . 3a ) and marked variation in mitral inflow doppler with respiration suggesting impending tamponade ( fig . microscopic exam revealed that the masses were composed of pink , amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes ( fig . after pericardiostomy the fever came down and hemoglobin rose up to 11.9 g / dl and crp came down to 0.84 mg / dl on the 30th day ( fig . we performed real time polymerase chain reaction ( pcr , lg life science , seoul , korea ) for mycobacterium tuberculosis using paraffin - embedded tissue , and confirmed that afb were mycobacterium species . it is very peculiar that tb pericarditis manifested as multiple free - floating pericardial masses in the effusion with impending tamponade . we assumed as follows . with great increase in permeability due to tb pericarditis , hemorrhage and fibrinous exudates developed in pericardial fluid . red blood cells and fibrinous and proteinous materials came into collision with each other , and they became conglomerated and bigger in size , and consequently discrete masses were formed in the pericardial effusion . this phenomenon might be accelerated by cardiac movement . with the compressive force in between the visceral and parietal pericardium , , we found at least two similar but different pediatric cases of tb pericarditis in taiwan and africa . lin et al . ( 4 ) reported a 10-month - old girl with fibrinofibrous pericarditis that manifested as constrictive pericarditis with prolonged fever , hepatomegaly , edema , and poor appetite . echocardiography showed a solid mass that originated from the thickened pericardium and compressed the whole heart . another similar african case was reported in 16-yr - old boy , who was hospitalized for fever , chest pain , and cardiovascular collapse . echocardiography revealed a 30-mm circumferential echogenic " porridge - like " pericardial effusion with signs of cardiac tamponade . the effusion in african case might be changing to solid mass similar to taiwan and our cases . pericardial involvement usually develops by retrograde lymphatic spread of m. tuberculosis from peritracheal , peribronchial , or mediastinal lymph node or by hematogenous spread from primary tuberculous infection ( 2 ) . pathologically , tb pericarditis is recognized as four stages : 1 ) fibrinous exudation with initial polymorphonuclear leukocytosis , relatively abundant mycobacteria , and early granuloma formation with loose organization of macrophage and t cells ; 2 ) serosanguineous effusion with a predominantly lymphocytic exudates with monocytes and foam cells ; 3 ) absorption of effusion with organization of granulomatous caseation and pericardial thickening caused by fibrin , collagenosis , and ultimately , fibrosis ; and 4 ) constrictive pericardium contracts on the cardiac chambers and may become calcified , encasing the heart in a fibrocalcific skin that impedes diastolic filling and causes the classic syndrome of constrictive pericarditis ( 6 ) . according to this classification , our case was clinically pericardial effusion , and pathologically in - between the stage 1 and 2 . but interestingly , our case had much more bleeding , because the masses were actually blood clots and the patient showed decreasing hemoglobin level . definitive diagnosis of tb pericarditis was based on 1 of following criteria : 1 ) positive mycobacterium tuberculosis culture from pericardial effusion or tissue , 2 ) positive afb or caseous granuloma on pericardial biopsy specimen , or 3 ) positive pcr in pericardial biopsy specimen ( 3 ) . the variability in the detection of tubercle bacilli in the direct smear examination of pericardial fluid ranges from 0% to 42% . positivity of cultures of the pericardial fluid ranges from 50% to 75% ( 2 ) . our case was positive for afb in both sputum and pericardial fluid , as well as positive pcr result in the tissue . echocardiographic findings of effusion with fibrous strands on the visceral pericardium are typical but not specific for tuberculous pathogenesis ( 1 ) . three echocardiographic features were emphasized in the diagnosis of tb pericarditis as follows ; 1 ) exudative coating defined as the presence of shaggy echo - dense images with mass - like appearance surrounding the epicardium , 2 ) fibrinous strands defined as multiple linear or band - like structures from the epicardium or pericardium protruding into the pericardial space , 3 ) thickened pericardium more than 2 mm on 2-dimensional echocardiogram ( 3 , 7 ) . the optimal management includes an open pericardial window with biopsy , both for diagnosis and to prevent re - accumulation of fluid ( 8) . since pericardiocentesis may fail in cases of advanced - stage fibrinous effusion , pericardiotomy with complete open draining is the only lifesaving procedure ( 5 ) . a regimen consisting of rifampicin , isoniazid , pyrazinamide , and ethambutol for at least 2 months , followed by isoniazid and rifampicin ( total of 6months of therapy ) has been shown to be highly effective in treating patients with extrapulmonary tb ( 2 , 9 ) . the american thoracic society 's consensus statement recommends adjunctive therapy with corticosteroids ( 1 mg / kg of prednisolone with tapering over 11 weeks ) for tuberculous pericarditis on the basis of two randomized , double - blind , controlled trials in south africa , although those studies had statistically no significant impact ( 9 ) . in the first study , patients in the later effusive - constrictive phase who received prednisolone had a significantly more rapid clinical resolution compared with patients given placebo . but , prednisolone did not reduce the risk of constrictive pericarditis ( 10 ) . in the second trial involving patients with effusive pericarditis , prednisolone reduced the need for repeated pericardiocentesis and was associated with significantly lower mortality ( 11 ) . according to the above american thoracic society 's consensus statement recommendation this is the unique report of a patient who rapidly developed tb pericarditis with free floating discoid masses in the effusion and impending tamponade during treatment of pulmonary tb .
pericarditis is a rare manifestation of tuberculosis ( tb ) in children . a 14-yr - old korean boy presented with cardiac tamponade during treatment of pulmonary tuberculosis . 
 he developed worsening anemia and persistent fever in spite of anti - tuberculosis medications . 
 echocardiography found free floating multiple discoid masses in the pericardial effusion . 
 the masses and exudates were removed by pericardiostomy . 
 the masses were composed of pink , amorphous meshwork of threads admixed with degenerated red blood cells and leukocytes with numerous acid - fast bacilli , which were confirmed as mycobacterium species by polymerase chain reaction . 
 the persistent fever and anemia were controlled after pericardiostomy . 
 this is the report of a unique manifestation of tb pericarditis as free floating masses in the effusion with impending tamponade .