TUBERCULOUS AORTITIS: SURGICAL RESECTION OF RUPTURED ABDOMINAL FALSE ANEURYSM

Aortic Involvement in Disseminated Tuberculosis – Challenges Beyond the Diagnosis

Tuberculous aortitis (TA) is a rare disease with a high mortality rate. Aortic pseudoaneurysm is the most common vascular pattern of TA, and isolated arterial wall thickening and arterial stenosis can also be seen in TA. We report two cases of disseminated tuberculosis involving the aorta with clinical improvement after treatment. One patient who had an aortic ulcer and intermural hematoma received anti-tuberculosis along with steroids therapy. The other patient, who developed a tubercular abdominal aortic pseudoaneurysm during anti-tuberculosis therapy, successfully received endovascular stent implantation. Clinicians should be aware that TA should be considered in patients with aortitis and active tuberculosis.

Ruptured tuberculous aneurysms of the abdominal aorta: Two case series

Background

Ruptured aneurysms secondary to the tuberculous infection of the aorta are a rare and life-threatening disease. We report a single-center experience of two patients with ruptured infrarenal tuberculous aneurysms.

Case presentation

We report 2 patients with ruptures of the tuberculous aneurysm. All patients had acute abdominal pain and were diagnosed by echography then CT scan preoperatively. The first patient (male, 50 years old) had a ruptured saccular aneurysm. The second patient (male, 43 years old) had a retroperitoneal contained rupture. All were treated by open prosthetic repair, by vascular surgeons. The two patients were well after operations. The diagnosis was confirmed by pathology examination. Antituberculous treatment was introduced after the operation.

Conclusions

Ruptured tuberculous aneurysms are rare but life-threatening. The diagnosis requires a high degree of suspicion. The treatment includes early diagnosis and emergent surgical intervention, extensive excision of infected field, aortic reconstruction, and prolonged antituberculous drug therapy.

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The tuberculous aortic aneurysm is a fatal condition if not early diagnosed and properly treated.

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The diagnosis requires a high degree of suspicion.

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Surgery is necessary for stenotic or aneurysmal lesions.

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The treatment should be a combination of surgery and antituberculous medication.

Endovascular repair combined with adjunctive procedures in the treatment of tuberculous infected native aortic aneurysms

OBJECTIVE

The present study aimed to analyze the experience of a single center and assess the efficacy and durability of endovascular aortic repair (EVAR) in patients with tuberculous infected native aortic aneurysms (INAAs).

METHODS

All patients who underwent EVAR for INAAs between September 2014 and August 2021 were retrospectively reviewed. The primary endpoints were 30-day and overall mortality rates; the secondary outcomes included major complications, endoleak, recurrence, re-intervention rate, and thrombosis of the pseudoaneurysmal sac.

RESULTS

A total of 18 patients (average age 61.3 years; 10 female [55.6%]) were identified. Fifteen patients (83.3%) had adjunctive procedures in addition to EVAR. Both the in-hospital and 30-day mortality rates were 0%. The overall cumulative survival rates estimated by Kaplan-Meier were 100% at 1 and 6 months, and 92.3% at 12, 24, and 80.8% at 36 and 48 months. Type Ib and II endoleak each occurred in 1 (5.6%) patient and resolved without treatment after 1 month. No graft infections, strokes, paraplegia, ischemic abdominal complications, or other major complications occurred. The overall rates of cumulative freedom from recurrence of aneurysm and re-intervention were 83.9% and 81.8%, respectively, during the median follow-up period of 28.5 (1-72) months. The median time of administering anti-tuberculosis drugs was 10.5 (2-44) months.

CONCLUSIONS

EVAR combined with oral anti-tuberculosis medication is effective and may be an appealing treatment option for high risk INAAs patients. Adjunctive procedures, including targeted drug delivery to the site of infection, could be a solution to further controlling the infection but still needs further evaluation.

Tuberculosis and the Heart

Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.

Endovascular treatment of multiple tuberculous mycotic aneurysm: A case report

RATIONALE

We present a rare case of multiple tuberculous mycotic aneurysm. Multiple aneurysms caused by tuberculosis (TB) are difficult to treat. Here, we discuss a treatment modality using a microcore stent graft.

PATIENT CONCERNS

A 73-year-old man with pain in the back and on the right side of the chest associated with dry cough, presented with an inability to walk since 1-month.

DIAGNOSES

A diagnosis of multiple aneurysms caused by TB was made, based on computed tomography (CT) scan and positive T-spot and Xpert tests.

INTERVENTIONS

We administered the empirical anti-TB regimen (pyrazinamide, isoniazid, rifampicin, and ethambutol) and performed endovascular repair using microcore stent graft.

OUTCOMES

The post-operative hemodynamic analysis indicated that the patient's aneurysms no longer had a risk of rupture, and blood flow in the major branches of the aorta had been maintained. However, the patient could not survive due to a pulmonary infection acquired during recuperation at a local hospital.

LESSONS

For multiple tuberculous mycotic aneurysms, anti-TB therapy is inadequate and the microcore stent graft is a feasible option that can improve the hemodynamics in the aneurysms.

18F-FDG PET/CT of Tuberculosis Meningitis and Carotid Pseudoaneurysm

A 26-year-old woman presented with a headache, left-sided weakness of the body, and pulsatile swelling above the sternal notch. She was treated for abdominal tuberculosis in the past, two years later she developed miliary tuberculosis and was put on modified regimen of antitubercular drugs in view of drug induced hepatitis. Ultrasound neck revealed saccular aneurysm measuring 4 x 3 cm, located in between common carotid arteries with an eccentric thrombus. MRI brain revealed multiple tuberculoma with thick basal meningeal enhancement. Cerebrospinal fluid was positive for Mycobacterium tuberculosis. F-FDG PET/CT was done to delineate the extent of the disease.

Aortoarteritis with tuberculosis

Aortoarteritis is an inflammatory condition of the aorta, which has been rarely reported due to tuberculous infection. We report two cases of children who had aortoarteritis along with tuberculosis (TB), of which one had collapse consolidation and the other had latent TB. Both patients were treated with anti-TB therapy and steroids.

Miliary tuberculosis in a patient with tuberculous mycotic aneurysm of the abdominal aorta: Case report and review of the literature

The combination of miliary tuberculosis and tuberculous mycotic aneurysm has been described in the literature. We present the case of an 84-year-old man who was diagnosed with a mycotic aneurysm of the abdominal aorta and an adjacent soft tissue mass, after a 3- month history of fever. The patient underwent endovascular restoration of the aneurysm and was treated with broad-spectrum antibiotics. One and a half months later the fever relapsed and the chest CT scan revealed findings consistent with miliary tuberculosis and opacities of both upper lobes not present before, while the abdominal CT scan revealed an increase in the size of the para-aortic mass. Tuberculosis was documented by positive culture for M. tuberculosis of bronchial washing and by the CT-guided para-aortic mass biopsy. The patient received anti-TB treatment for 9 months leading to a spectacular improvement of his clinical condition and imaging findings. A review of the literature since 2008 revealed 28 more cases of tuberculous mycotic aneurysm. The treatment and outcome of all cases are described. Mycotic aneurysm of tuberculous etiology remains a reality and has a relatively good prognosis. Although miliary tuberculosis affects mortality even elderly patients may benefit from "aggressive" management and treatment.

Tubercular mycotic aortic aneurysm: A case report

Tubercular aneurysms of larger vessels, particularly the aorta is very rare. The first case of tubercular involvement of the aorta in the form of aortitis was reported in 1882 by Weigert and the first case of tubercular mycotic aneurysm of the aorta was reported in 1895. The preoperative diagnosis of tubercular aortic aneurysm is difficult. Even at surgery, determining the tubercular nature of the lesion is problematic. The gross appearance may not be distinctive, and acid-fast stains are unlikely to be performed. We report the case of a young female patient who was started on antitubercular treatment for pleural effusion and was found to have aortic aneurysm, which later on proved to be tubercular in origin.

Tuberculous pseudoaneurysm of the ascending aorta

Increase in the incidence of drug resistance and association with HIV has led to a resurgence of tuberculosis. However, tubercular arteritis continues to remain a rare entity with a prelidection for the thoracic aorta. We report a tubercular ascending aortic pseudoaneurysm in a patient already on treatment for disseminated tuberculosis who underwent successful surgical repair and also review literature pertaining to this entity.

Tuberculosis of the renal artery: a rare cause of renovascular arterial hypertension

Tuberculosis is an endemic disease in Morocco. Main blood vessels are rarely affected; the few mentioned cases are aneurysmal. We report a 17-year-old patient presenting with renovascular arterial hypertension, revealed thanks to the discovery of an occlusion of the right renal artery in Duplex scan. During the intervention, the observation of pararenal and mesenteric tuberculous polyadenopathy let us suggest the same kind of lesion at the level of the occluded renal artery. Once antituberculosis treatment had been carried out, the right renal artery was revascularized with a right iliorenal bypass using reversed internal saphenous vein. The postoperative course was uneventful, with an 18-month follow-up. Arterial pressure was normal without antihypertensive treatment, and the bypass was patent. As far as we know, this is the first case of renovascular arterial hypertension resulting from tuberculosis treated with an iliorenal bypass.

[Thoracic infectious aortitis: microbiology, pathophysiology and treatment]

BACKGROUND

Thoracic infectious aortitis are currently rare. They are always lethal without any treatment. The microorganisms involved are numerous with particular pathophysiological characteristics for each bacterium. Treatment is difficult and must associate medical and surgical care.

RECENT FINDINGS

Bacterial epidemiology of infectious aortitis has been profoundly modified with the large use of antibiotics. Syphilitic aortitis were frequent in the beginning of the twentieth century but its incidence has dramatically fallen. It still exists and its clinical presentation must be known to begin an adequate treatment. Other bacterial aetiologies of these aortitis are more classical with high frequencies of Staphylococcus aureus and Streptococcus, which are often associated with infective endocarditis. Among Gram-negative bacteria, Salmonella spp are the most frequently met microorganisms. Atherosclerosis represents the principal risk factor of these infectious aortitis. It provokes arterial parietal damage useful for bacterial attach. A saccular aneurysm of infective origin can then appear. Treatment must consist on antibiotics before surgery; Tuberculous aortitis are also possible but are much more rare.

CONCLUSION

Thoracic infectious aortitis are very rare but must be known because of their poor prognosis. Treatment is difficult and prevention of atherosclerosis which is the most important risk factor of these diseases is therefore of greatest importance.

Repair of tuberculous aneurysm of distal aortic arch

A 65 year old female patient presented with one episode of massive haemoptysis requiring transfusion and subsequently cough with streaky haemoptysis. Computerized tomographic scan and angiogram revealed aneurysm of the distal aortic arch. She underwent elective repair of the pseudoaneurysm through median sternotomy and the bronchial communication was closed through left thoracotomy. Tubercle bacilli were identified in the contents and excised wall of aortic tissue.

Tubercular pseudoaneurysms of aorta

BACKGROUND

Tubercular pseudoaneurysm of aorta is a rare but important complication of tuberculosis. With worldwide resurgence of tuberculosis due to increasing incidence of drug-resistant tuberculosis and its association with acquired immunodeficiency syndrome, the tubercular pseudoaneurysm has become a real clinical entity.

METHODS

In the past 3 years, 5 young patients (22 to 40 years) presented with tubercular pseudoaneurysm. Site of involvement included ascending aorta, distal aortic arch, proximal descending thoracic aorta, distal descending thoracic aorta, and infrarenal abdominal aorta. Two patients had macroscopic focus of tuberculosis in the nearby vicinity, and all 5 patients had evidence of active/treated pulmonary pericardial tuberculosis. All patients either had received antitubercular therapy previously or were receiving it at the time of presentation. Rapid deterioration in the clinical status was the most marked clinical feature. All patients underwent operation. Graft interposition was performed in 2, patch repair in 2, and direct closure of the rent was performed in 1 patient. All 5 patients received antitubercular therapy in the postoperative period.

RESULTS

All patients survived the operation and were discharged from the hospital. One patient developed recurrence at the original site after 8 months and died at reoperation. The remaining patients are symptom free at 18 to 36 months postoperatively.

CONCLUSIONS

A combination of chemotherapy and operation yields gratifying results for the treatment of tubercular pseudoaneurysm.

Tuberculous aneurysm of the aorta presenting with uncontrolled hypertension

Mycotic aneurysm secondary to tuberculous infection of the aorta is a rare entity with less than 50 cases having been described in the literature. Clinical presentation is usually a consequence of the aneurysm, including pain, palpable mass, or hypovolemia secondary to leak. Definitive treatment is surgical, with nearly 30 documented successful cases. The authors present a case of tuberculous aortitis with mycotic aneurysms that presented with uncontrolled hypertension and occlusion of the right renal artery that underwent successful surgical repair.

Tuberculous infection of the descending thoracic and abdominal aorta: case report and literature review

We report here a case of infrarenal aortic disruption and aortoduodenal fistula secondary to tuberculous aortitis in a 77-year-old man. From a review of experience with operative management of tuberculous infection of the descending thoracic and abdominal aorta reported in the English-language literature, including the current report, we found that operative repair was attempted in 26 patients with tuberculous aortitis of the abdominal (n = 16), thoracic (n = 8), and thoracoabdominal (n = 2) aorta. Six patients had emergent operations for massive hemoptysis (n = 2), aortoduodenal fistula (n = 2), or abdominal rupture (n = 2), with an associated 30-day mortality of 50%. Elective or semi-elective repair was undertaken in 20 patients, of whom 19 (95%) survived for at least 30 days. On the basis of limited experience with this rare entity, in situ graft replacement is an appropriate treatment of tuberculous aneurysms and pseudoaneurysms of the descending thoracic and abdominal aorta.

Tuberculous mycotic aneurysm of the aorta: review of published medical and surgical experience

To define the epidemiology, pathogenesis, pathology, presentation, and management of tuberculous mycotic aneurysm of the aorta (TBAA) in the therapeutic era, we reviewed all of the cases reported in the English language literature from 1945 to the present. To the 39 cases in the published literature, we add two cases of our own. Although it is exceedingly rare, the prevalence of this lesion has remained relatively constant. In 75% of the cases, TBAA appeared to result from erosion of the aortic wall by a contiguous focus; 25% from direct seeding of the aortic intima or of the adventitia or media (via the vasa vasorum). Most of the aneurysms were saccular (90%) and false (88%). The thoracic and abdominal aortas were affected with equal frequency. The mean (+/- SD) age of the patients was 50+/-16 years. Twenty-two were men, and 19 were women. In 63% of the cases, tuberculosis (TB) was diagnosed at presentation. Disseminated TB was present in 46% of the cases. One or more of three clinical scenarios suggested TBAA: persistent pain, major bleeding, and a palpable or radiographically visible para-aortic mass, especially if it is expanding or pulsatile. In turn, each of these findings suggested a complication of TBAA that may be an indication for surgical intervention. Among the patients who were offered both medical and surgical treatment, 20 of 23 (87%) survived. Among those who were offered only one form of treatment or were offered no treatment at all there were no survivors. Both in situ reconstruction with a prosthetic graft, and extra-anatomic bypass appeared to offer excellent results, provided that an effective regimen of antituberculous drugs was delivered postoperatively. We offer our conclusions: (1) symptomatic TBAA is a rare but uniformly fatal lesion if not diagnosed promptly, (2) in the context of active TB, and especially miliary TB, TBAA should be suspected whenever one or more of the three clinical scenarios are present, and (3) combined medical and surgical therapy appears to offer the best chance of a cure.

Tuberculous pseudoaneurysm of the descending thoracic aorta: a case report and literature review of surgically treated cases

Tuberculous aneurysm of the aorta is an extremely rare disease with a high mortality rate. Only 32 patients treated surgically have been reported in the literature. These reports indicate an 84.4% operative survival rate. We present a case of a tuberculous false aneurysm in the descending thoracic aorta that was successfully treated surgically with an extracorporeal circulation. The hole in the aorta within the false aneurysm was closed with a Dacron patch because the aortic wall appeared to be free of active infection as a result of long-term preoperative antituberculous chemotherapy.

A case of Pott's disease of the spine eroding into the suprarenal aorta

Spinal tuberculous osteomyelitis eroding into the aorta is an extremely rare entity. The case of an 80-year-old man with a large proximal anastomotic pseudoaneurysm above an aortobiiliac prosthesis involving the suprarenal aorta is reported. A periaortic and perigraft fluid collection was found to be contiguous with an osteolytic process of the anterior bodies of the T12 and L1 vertebrae. Staged extraanatomic axillobifemoral bypass, graft excision, and viscerorenal revascularization with superficial femoral-popliteal veins were performed. The pathologic diagnosis of spinal tuberculous osteomyelitis was made. The rare entity of Pott's disease of the spine involving the suprarenal aorta and an aortic prosthesis presented significant challenges in resection and revascularization. The use of the deep veins of the legs as large-diameter autogenous conduit facilitated visceral and renal arterial bypass in an infected field.

Human immunodeficiency virus and infected aneurysm of the abdominal aorta: report of three cases

Three patients who were seropositive for human immunodeficiency virus underwent surgery for infected aneurysm of the abdominal aorta. Fever and abdominal pain were the principal presenting clinical features. None of the patients had any opportunistic infections or endocarditis. In two cases, a ruptured aneurysm was demonstrated radiographically. In the remaining case, sonograms were diagnostic. The organisms responsible were salmonella, Hemophilus influenzae, and Mycobacterium tuberculosis. In two cases, the infectious origin was evidenced by bacteriologic examination of the aortic wall, which revealed the presence of Salmonella enteritidis and Koch's bacillus. Although Hemophilus influenzae was not found in the aortic wall of the remaining case, the infectious origin of the aneurysm was established because preoperative blood cultures were positive for this pathogen, and pathohistologic examination of the specimen showed destruction associated with leukocyte infiltration of the aneurysmal wall. An in situ prosthetic graft replacement protected by omentum was performed in all three cases. Antibiotic therapy was continued for several weeks. All patients are well with follow-up ranging from 10 to 21 months. Infectious aneurysm associated with human immunodeficiency virus seropositivity results in bacterial infestation of an atheromatous aorta. Infected phenomena are promoted by cellular immunodeficiency. Surgery was justified in these cases because of the immediate threat of rupture.

Pulmonary tuberculosis with multiple saccular aneurysms of the aorta--a case report

A forty-eight-year-old man presented with cavitary pulmonary tuberculosis and widening of the mediastinum. Mediastinal widening was due to multiple saccular aneurysms of the ascending aorta and the arch of the aorta. The various presentations of tubercular aortitis and the reasons for considering alternative etiology for the thoracic aneurysms in this case are discussed. The authors report this interesting association of pulmonary tuberculosis with luetic aortic aneurysm.

A tuberculous pseudoaneurysm of the thoracic aorta presenting as massive hemoptysis--a case of successful surgical treatment

Tuberculous aneurysms of the aorta need early diagnosis and prompt surgical intervention because if untreated, they lead to severe consequences. We report herein, a case of a 63 year old woman who underwent successful resection of a tuberculous pseudoaneurysm which had ruptured into the left upper lobe of the lung after a punch biopsy, performed under bronchoscopy, had caused severe bleeding. Subsequent CT and MRI examinations suggested a fistula between the mass and the aorta and proved useful in establishing the diagnosis of a pseudoaneurysm. We wish to emphasize the need for bronchoscopy to be done carefully because of the risk of inducing massive hemoptysis.

Surgical treatment of a tuberculous thoracoabdominal aneurysm

We report a case of tuberculous thoracoabdominal aneurysm successfully treated by surgery. Computerized tomography was diagnostic for location and etiology. The therapeutic plan included antituberculosis drug therapy started before surgery, direct PTFE prosthetic replacement and omentoplasty. A survey of other reports dealing with tuberculous abdominal or thoracic aorta involvement shows that their frequency, as that of tuberculosis in general, is diminishing.

Tuberculous aortitis presenting with an aortoduodenal fistula: a case report

An elderly man with tuberculous aortitis presented with massive gastrointestinal bleeding resulting from an aortoduodenal fistula. Aortic resection was successful, and he has done well over a 12 year period. The organism was recovered from the aorta and also seen on section of the neighboring lymph nodes. Although tuberculous aortitis is rare, it should be considered in a patient with prior history of tuberculosis who has developed evidence of aortic disease, aneurysm, or massive gastrointestinal bleeding.

Tuberculous aortoarteritis

Tuberculous aortoarteritis is a distinct entity. Despite the still wide prevalence of active tuberculosis in developing countries, tuberculous aortoarteritis appears to be rare. The vessel is often involved by a direct extension of the disease from adjacent tuberculous tissue. Occasionally it may result from blood-borne seedlings from an active distant focus. True and false aneurysms are the common manifestations. Stenosing and/or constricting types of lesions and perivascular fibrosis have been encountered by us. The probable pathogenesis is discussed with illustrative cases.

Tuberculous aneurysms of the descending thoracic aorta: report of a case with fatal rupture

Tuberculous aortic aneurysm is a rare disease entity. The majority of affected patients succumb to perforation and exsanguination. The only chance for survival and cure is by resection and prolonged antituberculosis chemotherapy. Our case illustrates the high risk of rupture of tuberculous aortic aneurysms. Post-mortem examination revealed that the mechanism of aneurysm formation was by direct caseous involvement of the descending thoracic aorta from a juxtaposed left upper lobe parenchymal tuberculous process. Our findings also favor the concept that miliary dissemination (in the presence of tuberculous aortic aneurysm) is the result rather than the cause of the tuberculous aortic process.

Early diagnosis of tuberculous thoracic aortic aneurysm by computerized axial tomography

A thoracic aortic aneurysm secondary to miliary tuberculosis was successfully diagnosed early in its course in an asymptomatic patient by computerized axial tomography with contrast enhancement. This non-invasive technique, performed on an outpatient basis, led to the rapid and successful treatment of the patient.