Tuberculous myocarditis presenting as sudden cardiac death

Case report: Sudden unexpected death due to tuberculous myocarditis involving sinus node at autopsy

Tuberculous myocarditis (TM) is an extremely rare manifestation of Mycobacterium tuberculosis (TB) infection. Although TM is a critical cause of sudden cardiac death, only a few cases have been reported. We report the case of an older patient with pulmonary TB with a history of fever, chest tightness, paroxysmal palpitations, and electrocardiographic evidence of sinus node conduction abnormalities on admission. Although emergency physicians observed these unusual clinical manifestations, no timely differential diagnosis was made nor interventions were performed. A definitive diagnosis of TM and histopathological findings compatible with sinus node involvement were made based on autopsy outcomes. Herein, we describe the clinical presentation and pathological features of a rare form of Mycobacterium TB. In addition, we provide an overview of issues related to the diagnosis of myocardial TB.

Cardiac Tuberculosis on 18F-FDG PET Imaging—A Great Masquerader of Cardiac Sarcoidosis

A young gentleman with suspected cardiac sarcoidosis and LV dysfunction whose CMR revealed multifocal subepicardial to mid myocardial linear enhancement in the left ventricular myocardium underwent cardiac 18F-FDG PET imaging. The images revealed patchy regions of increased FDG uptake involving the apical to mid anterolateral, mid to basal anteroseptal/ right ventricular and mildly increased FDG uptake in apical inferior segments of the LV myocardium concordant with CMR findings. Whole body PET CT imaging showed multiple hypermetabolic supra and infra diaphragmatic lymphadenopathy, with no pulmonary lesion identified. Biopsy from the left para aortic lymph node revealed necrotizing granulomatous inflammation consistent with tuberculosis. Based on the histopathological findings of the lymph nodes, diagnosis of cardiac tuberculosis was made, given the similar imaging appearances in both sarcoidosis and TB. This case highlights that cardiac TB although rare, should be included in the differential diagnosis in patients with suspected infiltrative cardiomyopathy, particularly in TB endemic regions.

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.

Ventricular arrhythmia: A feature of tubercular myocarditis

Tuberculat myocarditis is an extremely rare entity with few published reports. We report a 13 year old male who presented with ventriculat tachycardia. On evaluation he was observed to have MRI features and workup consistent with nodular variant of tubercular myocarditis. Child had fatal outcome on follow up.

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.

Tuberculous myopericarditis: a rare presentation in an immunocompetent host

Tuberculosis is a common cause of pericardial disease in India. Myocardial involvement, although well described in the literature, is a rare manifestation of tuberculosis. We report a patient with disseminated tuberculosis and myopericarditis manifesting as cardiogenic shock. The patient gradually improved on antituberculosis drug therapy, steroids and an evidence-based guideline driven therapy for heart failure. Follow-up imaging showed calcification of the pericardium and improvement of his left ventricular systolic function.

Myocarditis at Post-Mortem Examination: A Forensic Perspective

Myocarditis is an uncommon cause of death but its myriad clinical presentations, young target population, diverse etiologies and potential to cause sudden unexpected death warrant its review. Myocarditis has been defined as myocardial necrosis and/or degeneration in the presence of an inflammatory infiltrate adjacent to the damaged myocytes. The type of predominant inflammatory cell present may assist with elucidating its pathoetiology. Ancillary testing as an adjunct to routine histopathological examination, such as immunohistochemical or immunofluorescence staining or detection of viral nucleic acid are of debatable diagnostic use in either the biopsy or autopsy setting. Myocarditis may clinically and/or histologically mimic other disease entities such as acute or organizing myocardial infarction, or hematological malignancy. There are no macroscopic pathognomonic features suggestive of myocarditis, thus in cases of unexplained sudden death it is vital to sample the heart extensively to rule out myocarditis. It is important to recognize that myocarditis may be an incidental finding in an autopsy. To attribute the cause of death to myocarditis, all relevant case findings including scene investigation, autopsy and ancillary testing including toxicology should be assessed.

State of the art in forensic investigation of sudden cardiac death

The sudden death of a young person is a devastating event for both the family and community. Over the last decade, significant advances have been made in understanding both the clinical and genetic basis of sudden cardiac death. Many of the causes of sudden death are due to genetic heart disorders, which can lead to both structural (eg, hypertrophic cardiomyopathy) and arrhythmogenic abnormalities (eg, familial long QT syndrome, Brugada syndrome). Most commonly, sudden cardiac death can be the first presentation of an underlying heart problem, leaving the family at a loss as to why an otherwise healthy young person has died. Not only is this a tragic event for those involved, but it also presents a great challenge to the forensic pathologist involved in the management of the surviving family members. Evaluation of families requires a multidisciplinary approach, which should include cardiologists, a clinical geneticist, a genetic counselor, and the forensic pathologist directly involved in the sudden death case. This multifaceted cardiac genetic service is crucial in the evaluation and management of the clinical, genetic, psychological, and social complexities observed in families in which there has been a young sudden cardiac death. The present study will address the spectrum of structural substrates of cardiac sudden death with particular emphasis given to the possible role of forensic molecular biology techniques in identifying subtle or even merely functional disorders accounting for electrical instability.

Sudden Cardiac Death due to Giant Cell Inflammatory Processes

Granulomatous inflammation of the myocardium may occur in a number of systemic disease processes including those with infectious etiologies such as fungal, mycobacterial and parasitic infections, as well as hypersensitivity reactions, and rarely autoimmune disorders. In many of these disorders, giant cells are components of the inflammatory infiltrate. Systemic granulomatous processes of unknown pathogenesis, most notably sarcoidosis, may also be associated with involvement of the myocardium. Occasionally, these disorders are associated with sudden death due to pathologic involvement of the heart. In contrast, giant cell myocarditis, also known as idiopathic myocarditis, a rare, frequently fulminant and fatal disorder of unknown etiology, is isolated to the heart and lacks systemic involvement. This disorder is most commonly diagnosed at autopsy. We present two cases in which sudden death resulted from a giant cell inflammatory process affecting the myocardium. Both individuals lacked antemortem diagnoses and collapsed at their respective places of employment. These cases compare and contrast the clinical and pathologic issues involved in the differential diagnoses of the subgroup of sudden cardiac deaths resulting from giant cell inflammatory processes that affect the myocardium, as well as the value of histologic examination and immunohistochemical studies.

Sudden death due to tuberculosis

Forensic pathologists deal not only with criminal, accidental and suicidal deaths, but also with a wide range of deaths from natural causes. Many of these deaths are sudden, unexpected, clinically unexplained or obscure, even though there need be no criminal element in their causation. Unnatural deaths have always to be investigated by the police, but very often natural deaths forms the basis of medico legal investigation, if they had occurred suddenly in apparently healthy persons. Often at autopsy these so called unnatural deaths may turn out to be natural and vice versa. Two cases of sudden death occurring in young individuals under suspicious circumstances are presented. On autopsy they were diagnosed to be secondary to tuberculosis.

Sudden Death from Tubercular Myocarditis

Tuberculous myocarditis is a rare finding. We present the case of a 33-year-old woman who was in good health and who died suddenly at home. Autopsy and histopathologic examinations revealed granulamatous lesions in the myocardium, lungs, lymph nodes, liver, and spleen. No fast acid bacilli were demonstrated on histological examination. The presence of a Mycobacterium tuberculosis DNA complex was identified using a polymerase chain reaction (PCR) on formalin-fixed paraffin-embedded histological samples. An HIV test carried out on the blood obtained during the autopsy was negative according to the DNA amplification technique (PCR) and enzyme-linked immunosorbent assay serological test. We hypothesize that the mechanism of death was severe ventricular arrhythmia due to granulomatous proliferation in the structures of the interventricular septum.

Current role of endomyocardial biopsy in the management of dilated cardiomyopathy and myocarditis

Dilated cardiomyopathy is a common cause of congestive heart failure. Despite a thorough cardiovascular evaluation, a specific cause is frequently not found, and the disorder then is considered idiopathic. Endomyocardial biopsy (EMB) may yield diagnostic and prognostic information in patients with idiopathic dilated cardiomyopathy; however, the yield of useful information with this procedure among patients with heart failure is low, and the risks of occasional cardiac perforation and death further limit its use. Recent publications in the field of myocarditis and cardiomyopathy have renewed interest in the use of EMB in select patients to diagnose specific and potentially treatable myocarditides; however, the role of EMB in the work-up of patients with dilated cardiomyopathy is not well defined. In this article, we discuss the risks and utility of EMB in the management of patients with dilated cardiomyopathy and specific myocarditides.

Tuberculosis and sudden death: a case report and review

Although deaths from tuberculosis (TB) are increasing, TB-related sudden death (TBRSD) is rarely reported in the literature. We present a case report of fatal pulmonary TB with extrapulmonary extension in a patient infected with the human immunodeficiency virus (HIV) and a review of published reports of TBRSD in MEDLINE (1966 to October 2000). Forty-six cases of TBRSD were reported. The most common cause of TBRSD was tuberculous bronchopneumonia in 30 (64%) patients, followed by hemoptysis in 14 (30%) patients. Tuberculous myocarditis and isolated TB of the adrenal glands are seldom causes of TBRSD. The early detection of TB, use of directly observed therapy, and individualization of treatment can be helpful in decreasing the incidence of TBRSD.

Tuberculous myocarditis presenting as long QT syndrome

An increasing QT interval can precipitate life-threatening tachyarrhythmias such as ventricular fibrillation. Tuberculous myocarditis is a very unusual diagnosis commonly made at autopsy. Mycobacterium tuberculosis can invade the cardiac conduction system and produce potentially dangerous arrhythmias. This case presents an HIV-infected man with tuberculous infection and long QT syndrome. We comment on the pathology, clinical features and outcome of this rare form of tuberculous infection.

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.