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.

Tuberculous False Aneurysm of the Aortic Isthmus Treated Using Stent Grafts.

Tuberculous aortic aneurysms are rare. Localization in the isthmus of the aorta is still exceptional. It often presents as a false aneurysm, which exposes to the risk of rupture, whatever the size of the aneurysm, and worsens the prognosis. The treatment of reference relies on surgery in association with antituberculosis treatment. The endovascular approach with stent grafts can be an alternative as presented in this case report, in which traditional surgery was judged to be at risk in a nonagenarian patient.

Mycobacterium bovis-induced Aneurysm after Intravesical Bacillus Calmette-Guérin Therapy: A Case Study and Literature Review.

Mycobacterium bovis infection after intravesical Bacillus Calmette-Guérin (BCG) therapy is rare. A 65-year-old Japanese man with history of bladder cancer and intravesical BCG therapy, presented with low-grade fever. An aneurysm with perianeurysmal fluid was suspected and endovascular aortic repair was performed. After 160 days, he developed blood-streaked sputum and computed tomography images revealed that the perianeurysmal fluid area was increasing in size. A multiplex polymerase chain reaction using sputum identified M. bovis. Treatment with anti-tuberculosis drugs reduced the size of the perianeurysmal fluid area. After intravesical BCG therapy, the possibility of M. bovis infection should be considered, thus further investigations are required.

Endografting under Assistance of Transapical Body Floss Through-and-Through Wiring Technique and Rapid Ventricular Pacing for an Ascending Aortic Tuberculous Pseudoaneurysm.

BACKGROUND: To demonstrate an ascending aortic tuberculosis pseudoaneurysm successfully treated with endografts under assistance of trans-apical body floss wiring technique and rapid ventricular pacing support. METHOD AND RESULT: A 77-year-old woman with a non-healing anteromedial chest wound presented with sudden hypotension and hemoptysis. The computed tomography (CT) scan revealed a 9-cm-diameter pseudoaneurysm of ascending aorta, with sternal erosion close to the wound. Conventional open repair was not preferred due to possible contamination of interposition graft and difficult sternum closure. The feasibility of endografting was confirmed based on appropriate landing zones. After endografts modification at back table, we made a left mini-thoracotomy and establish a through-and-through body floss wire from left ventricular apex to femoral artery. Retrograde delivery over this wire from femoral artery to ascending aorta and deployment of endografts under rapid ventricular pacing support were performed smoothly. Final angiography showed no endoleaks with patent coronary and arch vessels. Further wound debridement was done at the same time and wound culture yielded tuberculosis. After completing anti-tuberculosis therapy, no recurrent infection occurred. Postoperative 6-month CT scan disclosed optimal result. CONCLUSION: With adequate landing zones and delicate surgical strategy, endografting with anti-tuberculosis therapy may be an alternative treatment for ascending aortic tuberculosis pseudoaneurysm.

New insights on tuberculous aortitis.

OBJECTIVE: Aortitis is an exceedingly rare manifestation of tuberculosis. We describe 11 patients with tuberculous aortitis (TA). METHODS: Multicenter medical charts of patients hospitalized between 2003 and 2015 with TA in Paris, France, were reviewed. Demographic, medical history, laboratory, imaging, pathologic findings, treatment, and follow-up data were extracted from medical records. TA was considered when aortitis was diagnosed in a patient with active tuberculosis. RESULTS: Eleven patients (8 women; median age, 44.6 years) with TA were identified during this 12-year period. No patient had human immunodeficiency virus infection. Tuberculosis was active in all cases, with a median delay of 18 months between the first symptoms and diagnosis. At disease onset, vascular signs were mainly claudication, asymmetric blood pressure, and diminished distal pulses. Constitutional symptoms or extravascular signs were present in all patients at some point. Aortic pseudoaneurysm was the most frequent lesion, but three patients had isolated inflammatory aortic stenosis. TA appeared as extension from a contiguous infection in only three cases. Tuberculosis was considered because of clinical features, tuberculin skin or QuantiFERON-TB Gold (Quest Diagnostics, Madison, NJ) test results, pathologic findings, and improvement on antituberculosis therapy. A definite Mycobacterium tuberculosis identification was made in only three cases. All patients received antituberculosis therapy for 6 to 12 months. Surgery including Bentall procedures, aortic bypass, and open abdominal aneurysm repair was performed at diagnosis in eight patients. Seven patients received steroids as an adjunct therapy. All patients clinically improved under treatment. No patients died for a median follow-up duration of 4 years. CONCLUSIONS: TA may result in aneurysms contiguous to regional adenitis but also in isolated inflammatory aortic stenosis. Steroids may be associated with antituberculosis therapy for inflammatory stenotic lesions. Surgery is indicated for aneurysms and in case of worsening stenotic lesions despite anti-inflammatory drugs. No patient died after such combined treatment strategy.

Disseminated Mycotic Aneurysms following Intravesical Bacillus Calmette-Guérin Therapy for Bladder Cancer: Case Discussion and Systematic Treatment Algorithm.

Numerous case reports have highlighted the relationship between bacillus Calmette-Guérin (BCG) therapy and development of systemic mycotic aneurysms but none have established a management algorithm in patients with suspected vascular dissemination of Mycobacterium bovis. Delay in diagnosis of this disease process will lead to delays in initiation of antimycobacterium treatment to prevent dissemination into other arterial beds and potentially complicate effective surgical treatment leading to aneurysmal rupture and other devastating vascular consequences. Given the increasing number of reported cases in the literature and the ongoing, standard of care utilization of BCG for bladder cancer, we believe that a systematic approach to the management of patients with suspected BCG-related mycotic aneurysms should be set in place to prevent misdiagnosis and delays in treatment. In this report, we discuss the presentation, work-up, and report our treatment algorithm of a patient who developed diffuse peripheral mycotic aneurysms following BCG therapy for bladder cancer.

Death by aortoesophageal fistula due to disseminated tuberculosis: a case study.

Tuberculosis remains a serious public health problem worldwide, especially in Korea. Although tuberculosis is generally considered a non-fatal chronic disease, deaths have occurred. In this case study, a 68-year-old man was admitted to the hospital with dyspepsia, vomiting, and abdominal pain. Nine hours later, he suffered severe hematemesis and died despite cardiopulmonary resuscitation. A medico-legal autopsy was performed and an external examination revealed no external injuries. However, an internal examination revealed an aortoesophageal fistula and a large amount of blood in the stomach. A histologic examination confirmed tuberculous mediastinitis with disseminated tuberculosis involving multiple organs, including the heart, lungs, liver, kidneys, and spleen. Both an aortoesophageal fistula and sudden death due to tuberculosis infection are rare. This paper reports the case of a fatal aortoesophageal fistula associated with disseminated tuberculosis.

A rare but potentially lethal case of tuberculous aortic aneurysm presenting with repeated attacks of abdominal pain.

Tuberculous aortic aneurysm is an extremely rare disease with a high mortality rate. The clinical features of this condition are highly variable, ranging from asymptomatic with or without constitutional symptoms, abdominal pain to frank rupture, bleeding and shock. We herein report the case of a 56-year-old man with a large tuberculous mycotic aneurysm in the abdominal aorta with an initial presentation of repeated attacks of abdominal pain lasting for several months. Due to the vague nature of the initial symptoms, tuberculous aortic aneurysms may take several months to diagnose. This case highlights the importance of having a high index of suspicion and providing timely surgery for this rare but potentially lethal disease.

Successful treatment of a mycotic multifocal thoracoabdominal aortic aneurysm as a late sequelae of intravesical bacillus Calmette-Guerin therapy: case report and literature review.

Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis commonly used for the treatment of superficial bladder carcinoma. Intravesical BCG is well tolerated despite side effects that range from hematuria to sepsis syndrome. A very rare complication is vascular infection developing a mycotic BCG aneurysm, especially in the thoracoabdominal aorta (TAAA). These are challenging to diagnose because of their scarcity, nontraditional culture media, slow growth, and are often lethal. We report the first successful repair of a symptomatic, multifocal TAAA secondary to M bovis manifesting 17 months after intravesical BCG therapy and review the literature.

Ruptured mycobacterial aneurysm of the carotid artery.

Mycotic aneurysms resulting from intravesical bacillus Calmette-Guérin (BCG) treatment are exceptionally rare. We report on the case of a 73-year-old man who underwent intravesical therapy of BCG for bladder carcinoma and developed a right neck mass. A carotid pseudoaneurysm within a fibrotic mass was noted on surgical exploration. Radical resection was performed followed by a polytetrafluoroethylene interposition graft. Final pathology revealed necrotizing granulomas and multinucleated giant cells concerning for tuberculoma. Intravesicular BCG immunotherapy is an accepted treatment for patients with urothelial carcinoma. Carotid aneurysms are exceptionally rare in this setting and should prompt evaluation for systemic tuberculoid dissemination.

Abdominal aortic aneurysmal and endovascular device infection with iliopsoas abscess caused by Mycobacterium bovis as a complication of intravesical bacillus Calmette-Guérin therapy.

Vascular complications after the intravesical instillation of Bacillus Calmette-Guérin (BCG) therapy are extremely rare. We experienced a case of abdominal aortic aneurysmal infection excluded by a stent graft with an iliopsoas abscess after intravesical instillation of BCG therapy that required reoperation. Five years ago, an 81-year-old man was diagnosed with transitional cell carcinoma of the bladder. After transurethral resection of the bladder tumor and intravesical BCG therapy, a radical cystectomy was performed. Twenty-four months after intravesical BCG therapy, follow-up an abdominal computed tomographic (CT) scan revealed an aortic abdominal aneurysm. Endovascular aneurysm repair was performed, and the aneurysm was excluded postoperatively. Thirty months after the endovascular aneurysm repair (and 54 months after intravesical BCG therapy), a follow-up abdominal CT revealed a low-density area in the right iliopsoas muscle that formed a fistula to the excluded aneurysm. We performed CT-guided iliopsoas abscess drainage and collected yellow pus. Polymerase chain reaction analysis revealed that the pus was positive for Mycobacterium tuberculosis complex. The patient was diagnosed with abdominal aortic aneurysmal infection associated with iliopsoas abscess caused by Mycobacterium bovis, and surgery was performed. We performed an extra-anatomical bypass and removed the stent graft with debridement. When the aneurysmal wall was incised and resected, yellow pus surrounded the stent graft. In addition, a large fistula was present between the right posterolateral aortic aneurysmal wall and the iliopsoas abscess cavity. After the operation, the histopathological examination of excised abdominal aortic aneurysmal wall tissue revealed an epithelioid granuloma with caseous necrosis involving multinucleated giant cells, indicating M tuberculosis complex infection. Although the intravesical instillation of BCG therapy is considered safe, complications resulting from vascular infections can arise in extremely rare cases. The complication described in this case report emphasizes the need to cautiously select treatment for a mycotic aortic aneurysm after intravesical instillation of BCG therapy.

Tuberculous ascending aortic pseudoaneurysm.

Pseudoaneurysms of the ascending aorta due to infective organisms are a rare but challenging entity with a risk of high morbidity and mortality. Previous cardiac surgery is an attributing factor, but they can present without previous surgical interventions. Various micro-organisms are responsible for this pathology. Tuberculous pseudoaneurysms of the ascending aorta are extremely rare. We report a case of a 25-year old man who presented to us with shortness of breath and recurrent haemoptysis. After preoperative evaluation including clinical and radiological assessment and echocardiography, he underwent successful repair of a pseudoaneurysm of the ascending aorta by excision and replacement of the diseased aorta with a Dacron tube graft using cardiopulmonary bypass. Postoperatively, he was started on antituberculous chemotherapy based on histological findings.

Combined infection of vertebroplasty and aortic graft after intravesical BCG treatment.

We report a 58-year-old man with spondylodiscitis by Mycobacterium bovis-BCG 3 years after intravesical BCG treatment, and shortly after a vertebroplasty. Further examination showed a psoas abscess and oedema around an endovascular aortic graft, which had been placed 1 year earlier. Puncture of the psoas abscess also grew M bovis-BCG. The patient recovered with a combination of antituberculous treatment and surgery. With hindsight a mycotic aneurysm had been present at the time of aortic graft placement and spondylodiscitis at the time of vertebroplasty. This case shows that low grade and longstanding infections may occur following intravesical BCG installation.

Endovascular aneurysm repair of tuberculous mycotic abdominal aortic aneurysm on a patient with renal transplant.

The case report describes a gentleman with renal transplant who presented with pulmonary tuberculosis (TB) and mycotic aneurysm of abdominal aorta. The aneurysm was successfully treated with endovascular aneurysm repair. A multidisciplinary approach with renal physicians and infectious diseases unit was necessary to treat TB and maintain immunosuppression. The technique used for deployment of the stent graft in the presence of infection and a transplanted kidney is described. The satisfactory outcome at 5 years follow-up indicates that endovascular option for TB mycotic aneurysm is durable and safe option particularly when major open surgery is associated with significant mortality and morbidity.

Tuberculous iliac artery aneurysm in a pediatric patient.

Vascular complications of tuberculous infections are rare and occur even less frequently in the pediatric population. Tuberculous pseudoaneurysms can occur either as a result of contiguous spread from a neighboring focus-invariably infected lymph nodes-or by hematogenous spread and seeding of acid-fast bacilli that lodge in the adventitia or media via the vasa vasorum. We report a case of turberculous right common iliac artery pseudoaneurysm in a 12-year-old and review the relevant literature.

A Mycobacterium bovis mycotic abdominal aortic aneurysm resulting from bladder cancer treatment, resection, and reconstruction with a cryopreserved aortic graft.

Mycotic abdominal aortic aneurysms (AAAs) are a clinical challenge for vascular surgeons due to their critical location, surrounding inflammation, risk of rupture, and danger of reinfection following treatment. We present a case of Mycobacterium bovis AAA in a 69-year-old male after treatment with intravesicular bacillus Calmette-Guérin (BCG) therapy for bladder carcinoma. The classical approach for mycotic AAA entails extra-anatomic reconstruction followed by resection with oversewing of the proximal and distal aortic stumps. Alternative in-line reconstruction options have also been advocated. This case illustrates a technically straightforward, durable, in-line repair within an infected field utilizing cryopreserved aortic allograft.

Endovascular aneurysm repair of saccular descending thoracic pseudoaneurysm possibly associated with tuberculosis.

In 2010, an 84-year-old man underwent thoracic endovascular aneurysm repair (TEVAR) for the saccular descending thoracic pseudoaneurysm (DTAA), which was adherent to the pulmonary lobe and thoracic vertebrae. Past medical history comprised twice anti-tuberculous medications for pulmonary tuberculosis and tuberculous vertebral osteomyelitis. The dilated aorta was detected at the time of medication for tuberculous vertebral osteomyelitis 24 years ago. However, he was not indicated for the operation, and he was lost to follow-up until now. The association of tuberculosis bacilli was suspected through clinical course as an origin of DTAA, although the histopathological examination was not performed because of invasion. TEVAR was performed considering: (1) no preoperative ongoing inflammation, (2) no evidence of tuberculosis recurrence, and (3) risk factors, such as pulmonary impairments and high age. Several months have been passed since the operation, and the patient remains well without perioperative anti-tuberculous medications.

A rare disappearing right atrial mass.

Cardiac tuberculosis is rare and usually involves the pericardium. Myocardial tuberculoma is a very rare occurrence and only a few cases have been reported. We describe a rare case of cardiac tuberculoma involving the whole of the lateral right atrial wall, extending from the superior vena cava/right atrial junction up to a tricuspid valve. The initial diagnosis of right atrial myxoma was made based on the echocardiography report and surgical excision was planned. Intraoperatively, the excision of the mass was deferred due to the extensive nature of the disease and a high suspicion of malignancy. Cardiac tuberculoma was confirmed by histopathological examination. The patient made a remarkable recovery with the complete disappearance of the mass after anti-tuberculous treatment, as viewed by a postoperative echocardiography during the follow-up.

Endovascular treatment of a tuberculous thoracoabdominal aneurysm with the Multilayer stent.

PURPOSE: To describe a case of multiple thoracoabdominal aneurysms of tuberculous origin treated in an endovascular procedure with the Multilayer stent. CASE REPORT: A 16-year-old girl had been treated 4 years previously for a ruptured abdominal aortic aneurysm of tuberculous origin. Due to the presence of 4 rapidly evolving saccular aneurysms of the descending thoracic aorta and a fusiform aneurysm of the suprarenal aorta, an endovascular solution was chosen after the patient refused open surgery. Three uncovered Multilayer stents (16×40, 16×80, and 16×80 mm) were successively implanted with a 1-cm overlap from the left subclavian artery to cover the entire aneurysmal segment of the thoracoabdominal aorta to above the renal arteries. At 18 months, serial imaging studies have shown disappearance of some aneurysms and regression of others. CONCLUSION: In this young patient, the endovascular treatment of a thoracoabdominal aneurysm with an uncovered stent made it possible to stabilize the aneurysm process without exposing the patient to the high morbidity and mortality of open surgery.