Tuberculoma of the heart. Report of 9 cases

Cardiac Tuberculoma Presenting as Sudden Cardiac Death in an Immunocompetent Young Man: A Case Report and Literature Review

Tuberculosis is one of several preventable and curable communicable diseases that is a major cause of morbidity and one of the top ten causes of death worldwide. Cardiac tuberculosis frequently affects the pericardium. Although rare, most cases of tuberculosis involving the myocardium and endocardium present as sudden cardiac death in asymptomatic cases. Information about the myocardial involvement of tuberculosis appears in the literature once in a blue moon. As a result, there is a knowledge gap about cardiac tuberculosis among health professionals. Here, a case of sudden cardiac death from tuberculoma of the right atrium with a secondary thrombus causing bicaval obstruction that is observed in an asymptomatic immunocompetent young man is presented. Furthermore, challenges related to the diagnosis and management of cardiac tuberculosis are discussed, and an overview of the relevant literature is provided to break new ground in early diagnosis and therapy.

Cardiovascular Involvement in Tuberculosis: From Pathophysiology to Diagnosis and Complications-A Narrative Review

Although primarily a lung disease, extra-pulmonary tuberculosis (TB) can affect any organ or system. Of these, cardiovascular complications associated with disease or drug toxicity significantly worsen the prognosis. Approximately 60% of patients with TB have a cardiovascular disease, the most common associated pathological entities being pericarditis, myocarditis, and coronary artery disease. We searched the electronic databases PubMed, MEDLINE, and EMBASE for studies that evaluated the impact of TB on the cardiovascular system, from pathophysiological mechanisms to clinical and paraclinical diagnosis of cardiovascular involvement as well as the management of cardiotoxicity associated with antituberculosis medication. The occurrence of pericarditis in all its forms and the possibility of developing constrictive pericarditis, the association of concomitant myocarditis with severe systolic dysfunction and complication with acute heart failure phenomena, and the long-term development of aortic aneurysms with risk of complications, as well as drug-induced toxicity, pose complex additional problems in the management of patients with TB. In the era of multidisciplinarity and polymedication, evidence-based medicine provides various tools that facilitate an integrative management that allows early diagnosis and treatment of cardiac pathologies associated with TB.

Tuberculosis of the Heart: A Diagnostic Challenge

Tuberculosis of the heart is relatively rare and presents a significant diagnostic difficulty for physicians. It is the leading cause of death from infectious illness. It is one of the top 10 leading causes of death worldwide, with a disproportionate impact in low- and middle-income nations. The radiologist plays a pivotal role as CMR is a non-invasive radiological method that can aid in identifying potential overlap and differential diagnosis between tuberculosis, mass lesions, pericarditis, and myocarditis. Regardless of similarities or overlap in observations, the combination of clinical and certain particular radiological features, which are also detected by comparison to earlier and follow-up CMR scans, may aid in the differential diagnosis. CMR offers a significant advantage over echocardiography for detecting, characterizing, and assessing cardiovascular abnormalities. In conjunction with clinical presentation, knowledge of LGE, feature tracking, and parametric imaging in CMR may help in the early detection of tuberculous myopericarditis and serve as a surrogate for endomyocardial biopsy resulting in a quicker diagnosis and therapy. This article aims to explain the current state of cardiac tuberculosis, the diagnostic utility of CMR in tuberculosis (TB) patients, and offer an overview of the various imaging and laboratory procedures used to detect cardiac tuberculosis.

Myocardial tuberculosis and beyond: A rare form of extra pulmonary TB in a young boy

Myocardial tuberculosis is an exceptionally rare form of extra-pulmonary TB. Few cases were reported world-wide. Here a young snake charmer who had skin tuberculosis 5 yrs back admitted into National institute of diseases of Chest and hospital (NIDCH), Dhaka with the complaints of cough, palpitation and breathlessness for 2 months. He had right axillary firm matted lymphadenopathy, left sided large pleural effusion, left ventricular and septal hypertrophy with band and mass inside the ventricle (evident on CT scan of heart and echocardiography). His ESR was 95 mm in1st hr, Mantaux test was 15mm, Pleural fluid was exudative lymphocyte predominant with adenosin deaminase (ADA) 68.6 U/L. Fine needle aspirates from right axillary LNs showed Mycobacterium tuberculosis on GeneXpert for MTB/RIF testing and caseous granuloma on cytopathological study. Whole Body F18 FDG PET-CT revealed numerous low FDG avid size significant lymph nodes in right side of neck, mediastinum and right axilla with cardiomegaly with focal FDG avid within the left ventricular cavity likely to be prominent papillary muscle. MRI of heart or Myocardial biopsy for histology was not done due to their cost and invasiveness and also for that there was sufficient evidence of having tuberculosis in lymph node, pleura nas myocardium. This patient was treated with anti tubercular medications (3HRZE2S/5HRE) with prednisolone for six months. After treatment, myocardial lesions, pleural effusion and lymphadenopathy were found resolved. Thus a case of fatal and serious tuberculosis was explored and managed successfully.

Thoracic Cardiovascular Complications of Tuberculosis

ABSTRACT

Mycobacterium infection remains a leading cause of morbidity and mortality worldwide. Although rare, thoracic cardiovascular complications are associated with devastating consequences if not promptly diagnosed using computed tomography. Intrapulmonary complications include tuberculous aortitis, Rasmussen aneurysms, involvement of bronchial and nonbronchial systemic arteries, and thromboembolic events. Extrapulmonary complications include pericarditis, myocarditis, endocarditis, involvement of coronary arteries, annular-subvalvular left ventricle aneurysms and mediastinal fibrosis. This article will review these complications and their computed tomography features.

Management of patients with myocardial tuberculosis: A case series

BACKGROUND

Myocardial Tuberculosis (MT) is exceedingly rare. We aimed to report on myocardial involvement in tuberculosis (TB).

METHODS

All adult patients admitted in a department of Internal Medicine over an 8-year period with microbiologically proven MT were retrospectively reviewed. Demographic, medical history, laboratory, imaging, pathologic findings, treatment, and follow-up data were extracted from medical records.

RESULTS

Six patients (4 women, 37.6 [21.3-62.1] years) with MT were identified. MT included cardiac mass (n = 1), coronaritis (n = 1), left ventricle spontaneous rupture (n = 1) and myocarditis (n = 3). Pericardial effusion was associated with myocardial involvement in 2 cases. Four patients presented with acute heart failure. CRP serum level was high in all cases. The mean delay between the first symptoms and TB diagnosis was of 6 [1-44] months. The time from admission to diagnosis was of 18 (9-28) days. No patient had human immunodeficiency virus infection. Fluorodeoxyglucose - positron emission tomography (FDG-PET) detected extra-cardiac asymptomatic Mycobacterium tuberculosis infection localization and guided biopsy in 5 cases. As compared to TB patients without cardiac involvement, patients with MT were younger and more frequently women. All patients received antituberculosis therapy for 7.5 to 12 months associated with steroids for at least 6 weeks. Cardiac surgery was required in all but one patient. No patient died over a median follow-up of 1.2 [0.2-4.4] years.

CONCLUSION

Our study emphasizes the clinical spectrum of life-threatening MT. Early diagnosis using FDG-PET imaging to target biopsy in extra-cardiac tissues and combined treatment strategy associating antituberculosis therapy, corticosteroids and surgery prevent complications and death.

Sudden death caused by pulmonary fat embolism in a patient with miliary tuberculosis

An 84-year-old Japanese woman with myelodysplastic syndrome was admitted with pyrexia and dyspnea, but died suddenly during diagnostic evaluation. The autopsy revealed miliary tuberculosis in addition to myelodysplastic syndrome in the bone marrow. The immediate cause of the patient’s sudden death was pulmonary fat embolism derived from bone marrow necrosis. This case shows that the infiltration of the myelodysplastic bone marrow by tuberculosis and consequent bone marrow necrosis and fat embolism can be the cause of sudden death. In this article, we report the autopsy results of this unusual cause of sudden death, and discuss tuberculosis-related sudden death with a review of the literature.

Parachute-Like Mitral Valve Tuberculoma: A Rare Presentation

There have been anecdotal reports of tuberculous cardiac involvement, mainly in cases of military tuberculosis or immune deficient individuals. The spectrum of clinical presentations of tuberculous cardiac involvements includes incidental detection of single and multiple well-circumscribed tuberculomas, symptomatic obstructive lesions, AV conduction abnormalities, and even sudden death. We present a case of cardiac tuberculoma in an immune-competent person who presented with worsening dyspnea. The unique morphology of this mass posed an imaging challenge that required 4-dimensional (4D) echocardiography and cardiac magnetic resonance (CMR) detail to differentiate the mass from an anterior mitral leaflet (AML) aneurysm. Histological examination after surgical resection confirmed its tuberculous etiology.

Diagnostic challenges in a patient with myocardial tuberculoma: A case report

INTRODUCTION

Tuberculosis can affect any organ of the body, including the heart.

PRESENTATION OF CASE

An 18-year old woman presented with a multifocal tuberculosis infection involving abdominal lymph nodes, a sternotomy wound, an abscess of the abdominal wall and most notably a myocardial tuberculoma. Establishing the diagnosis of the myocardial tuberculoma was challenging mainly due to the location within the heart. Initially a diagnostic percutaneous femoral vascular catheter guided biopsy of the right atrial mass was performed, but later open surgery involving median sternotomy was needed. The patient recovered fully after surgery and nine months treatment with anti-tuberculosis drugs.

DISCUSSION

The optimal length of treatment for myocardial tuberculoma is unknown. Medical treatment for six months might be enough regardless whether surgery is performed or not.

CONCLUSION

Myocardial tuberculoma requires culture from the infected tissue for confirmed diagnosis and might be successfully treated with anti-tuberculosis drugs only. Indications for surgery include uncertain diagnosis, poor response to medical treatment or cardiac complications.

[Myocardial tuberculoma: unusual location of tuberculosis: a new observation and review of the literature]

Nous rapportons l'observation d'un patient de 50 ans présentant une masse tumorale du ventricule gauche évoluant dans un contexte d'altération de l’état général et de fièvre. Cette masse a été objectivée par l’échocardiographie réalisée pour l'exploration d'une cardiomégalie radiologique. L'aspect en imagerie par résonance magnétique était évocateur d'un tuberculome intra myocardique. A travers notre observation, nous proposons une revue de la littérature sur cette localisation inhabituelle de la tuberculose.

Tuberculous endocarditis: valvular and right atrial involvement

Valvular endocarditis due to Mycobacterium tuberculosis is a rare clinical entity. It is usually manifest in the context of disseminated tuberculosis in immunocompromised patients. This report describes a unique case of a 30-year-old immunocompetent man with an incidental finding of tuberculous valvular endocarditis. The patient had a large mass on the anterior mitral leaflet and severe mitral regurgitation. He underwent mitral valve replacement and Mycobacterium tuberculosis was cultured from the valve vegetation and the right atrial masses. Post-operative recovery has been uneventful without relapse for 24 months.

A case of tuberculous endocarditis with acute aortic valve insufficiency and annular subvalvular left ventricular aneurysm

Tuberculous endocarditis is an exceptionally rare disease, and its surgical operation has been reported in only one case. This is a successful surgical report of acute aortic insufficiency caused by tuberculous endocarditis associated with annular subvalvular left ventricular aneurysm (ASLVA) beneath the aortic valve. This patient had acute left ventricular failure and cardiorespiratory arrest and suffered from multiple organ dysfunction and coagulopathy disorder. Urgent surgery was performed to replace the aortic valve with the approximation of ASLVA. Histopathological findings of the excised aortic cusps gave the diagnosis of tuberculous endocarditis, and antituberculous drug administration started on the first postoperative day. Postoperative recovery has been uneventful without relapse of tuberculosis for 7 postoperative years.

Tuberculous dilated cardiomyopathy: an under-recognized entity?

BACKGROUND

Tuberculosis (TB) is a common public health problem in many parts of the world. TB is generally believed to spare these four organs-heart, skeletal muscle, thyroid and pancreas. We describe a rare case of myocardial TB diagnosed on a post-mortem cardiac biopsy.

CASE PRESENTATION

Patient presented with history suggestive of congestive heart failure. We describe the clinical presentation, investigations and outcome of this case, and review the literature on the involvement of myocardium by TB.

CONCLUSION

Involvement of myocardium by TB is rare. However it should be suspected as a cause of congestive heart failure in any patient with features suggestive of TB. Increasing recognition of the entity and the use of endomyocardial biopsy may help us detect more cases of this "curable" form of cardiomyopathy.

An intracardiac mass in a young man with congenitally acquired HIV

A case of a 19-year-old man with congenitally acquired HIV infection who was found to have a large intracardiac mass is presented. Presurgical imaging studies and subsequent pathologic findings and histology are discussed.

Cardiac tuberculosis with multiple intracardiac masses: a case report

In this report, clinical, echocardiographic, and pathologic findings of a patient with multiple masses caused by tuberculosis both in the left and right side of the heart are presented. After antituberculosis treatment some of the masses disappeared and some became smaller. Although an intracardiac mass caused by tuberculosis is very rare, it should be considered in the list of masses detected by echocardiography.

Sudden death caused by myocardial tuberculosis: case report and review of the literature

A 25-year-old fit man died suddenly while playing social soccer. Autopsy revealed an infiltrative lesion involving the left ventricle with overlying pericarditis. No other significant pathologic changes were observed. Histologic examination showed necrotizing granulomatous inflammation. No acid-fast bacilli were demonstrated in the pericardial fluid or on histologic examination. The presence of Mycobacterium tuberculosis DNA complex was confirmed by use of the ligase chain reaction technique. The differential diagnosis of myocardial tuberculosis includes sarcoidosis, rheumatic fever, rheumatoid arthritis, giant-cell-containing tumors, idiopathic (giant-cell) myocarditis, and bacterial infections such as tularemia and brucellosis. This case illustrates the protean manifestations of tuberculosis and highlights the use of molecular biologic techniques in arriving at a definitive diagnosis in cases of suspected tuberculosis.

Obstruction of the right ventricular outflow tract caused by a tuberculoma in a patient with ventricular septal defect and aneurysm of the membranous septum

Reported here is an obstruction of the right ventricular outflow tract caused by a tuberculoma in a 15-year-old boy who presented with a ventricular septal defect. The obstruction was discovered at surgery and the tuberculous aetiology was only demonstrated histologically. To the authors' knowledge, this is the first report of a tuberculoma of the heart associated with congenital heart disease.

Pancardiac tuberculosis--a case report

The authors report a very unusual and unique case of pancardiac tuberculosis in a 25-year-old man who presented initially with atrial flutter with 1:1 conduction. Echocardiographic findings, computerized tomography images, and pathology specimens are presented. After initiation of antituberculous therapy, the patient converted to normal sinus rhythm.

Constrictive pericarditis causing extrinsic mitral stenosis and a left heart mass

Constrictive pericarditis is a fibrotic process involving both layers of the pericardium and is known to give rise to obstruction to blood flow in the right heart. We report a patient with constrictive pericarditis who had echocardiographic features of mitral stenosis caused by a fibrocalcific mass lesion involving the mitral annulus with infiltration into the base of the posterior mitral leaflet. To our knowledge, this has not been reported in the literature.

Results of echocardiographic examinations in a regional hospital of central Sudan

Sixty-seven patients were examined with a small portable echocardiograph in Wad Medani Teaching Hospital in central Sudan. The cardiac alterations detected in the referred patients, namely valvular disease and pericardial effusion, suggested a high prevalence of inflammatory heart disease in this area. Other findings were dilatative cardiomyopathy, congenital heart disease, mitral valve prolapse and a cardiac mass. Echocardiographic examination of patients with advanced hepatosplenic schistosomiasis revealed no evidence of cardiac alterations or abnormal right heart function. For echocardiography a general purpose ultrasound scanner, as defined by the World Health Organization, was used, additionally equipped with M mode facilities. It was concluded that echocardiography is applicable even in remote tropical areas and that its value, considering costs, therapeutic consequences and clinical benefit in developing countries, can be substantial. It was particularly helpful with pericardial disease.

Myocardial tuberculoma with rupture and pseudoaneurysm formation--successful surgical treatment

A case of left ventricular pseudoaneurysm due to rupture of a myocardial tuberculoma is presented. The diagnosis of pseudoaneurysm was initially suggested by echocardiography and was confirmed by angiocardiography. The aetiology was suggested at operation and confirmed by histological examination. This is a very rare condition which is usually diagnosed only at necropsy.

Right atrial tuberculoma: report of a case with complete recovery

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Cardiac tuberculosis: TB of the endocardium

Tuberculosis involving the endocardium is extremely rare. The diagnosis is usually made during autopsy. Often there is involvement of other parts of the heart as well as other regions of the body. The infection is a result of direct extension from the myocardium or hematogenous spread. Two cases of disseminated tuberculosis with endocardial involvement are reported. In Case 1 miliary tuberculosis was diagnosed during life but the patient succumbed to extensive disease on the third hospital day. The patient in Case 2 presented with congestive cardiac failure and the possibility of tuberculosis was not suspected during life.

Sudden death due to myocardial tuberculosis

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Myocardial tuberculosis

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