However, the patient developed persistent cough, dyspnea, and shortness of breath over one month, showing no improvement with conventional management, along with several palpable cervical lymph nodes. Chest computed tomography revealed a large pericardial effusion with impending tamponade physiology and diffuse parenchymal infiltration in the left lung field (Fig. 2A). Ultrasound-guided biopsy of the cervical lymph nodes revealed granulomatous inflammation with necrosis (Fig. 2B). Pericardiocentesis drainage was performed, showing positive AFB with M. tuberculosis culture, and adenosine deaminase (ADA) 11.3 IU/L, which was compatible with tuberculous pericarditis, and IGRA result were positive. Standard anti-tuberculosis medication (HREZ) was initiated for six months with rapid symptom improvement (Fig. 2C, D).

Pericarditis is an important extra-pulmonary presentation of tuberculosis. Its late diagnosis may result in serious complications, such as constrictive pericarditis, cardiac tamponade, and increased mortality rate [1]. Tuberculous pericarditis can be diagnosed by examining the pericardial exudate or by detecting a good response after anti-tuberculous drug use in patients with pericarditis [2]. High ADA levels have also been associated with tuberculous pericarditis [3]. Early suspicion and prompt management in patients with immunosuppressive treatment are crucial for improving treatment outcome of tuberculous pericarditis [4,5].