Obstructive Shock due to Cardiac Tamponade Secondary to Tubercular Massive Pericardial Effusion in a Patient with Ankylosing Spondylitis on Tofacitinib Therapy: A Case Report

Abstract

Pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. Because of the limited amount of space in the pericardial cavity, fluid accumulation leads to an increased intrapericardial pressure which can negatively affect heart function. A pericardial effusion with enough pressure to adversely affect heart function is called cardiac tamponade. Pericardial effusion usually results from a disturbed equilibrium between the production and re-absorption of pericardial fluid, or from a structural abnormality that allows fluid to enter the pericardial cavity. Tuberculosis involvement of the pericardium is well-known and can result in pericardial tamponade apart from other sequelae like constrictive pericarditis.  Tuberculous pericarditis (TBP) is due to hypersensitivity to tuberculin protein produced by Mycobacterium tuberculosis and develops in 1-2% of pulmonary TB cases, representing about 1-2% of extrapulmonary tuberculosis. Complications occur in the form of acute pericarditis (4%) and cardiac tamponade (7%), which may require life-saving invasive procedures.  Risk factors include diabetes, substance use disorder, HIV-positivity, renal insufficiency, biological or immunosuppressive therapy, and exposure to regions with a high prevalence of tuberculosis. Latent tuberculosis infection (LTBI) reactivation is a well-known risk associated with immunosuppressive therapies employed in the treatment of ankylosing spondylitis (AS). Tofacitinib, an approved medication for AS that inhibits Janus kinases, has been associated with an elevated risk of TB reactivation.  Here we report a case of 40 years old male, who is a known case of ankylosing spondylitis on tofacitinib therapy presented with short duration of fever and acute onset breathlessness. Urgent echocardiography shows cardiac tamponade. Pericardiocentesis was performed immediately and more than one-liter hemorrhagic fluid drained. Patient was put on anti-tubercular treatment with oral steroid after adenosine deaminase positivity and gene X pert TB positivity in exudative pericardial fluid.

Bangladesh Journal of Infectious Diseases, June 2025;12(1):167-173