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.

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.

Takayasu's or tuberculous arteritis?

Takayasu's arteritis (TA) is a large vessel vasculitis of unknown aetiology characterised by involvement of the aorta and its major branches. Tuberculous arteritis of the aorta is an uncommon condition usually secondary to the dissemination of Mycobacterium tuberculosis infection from the mediastinum and/or lung to the adjacent aorta; this may mimic TA. We report a case of a 23-year-old woman with cutaneous granulomatous vasculitis and saccular aneurysmal dilation of the aorta and large vessels, and highlight the findings shared by TA and tuberculous arteritis.

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.

Endovascular stent graft placement in the treatment of a ruptured tuberculous pseudoaneurysm of the descending thoracic aorta secondary to Pott's disease of the spine.

Ruptured thoracic aortic tuberculous pseudoaneurysms as a complication of mycobacterium tuberculosis infection of the spine are rare. Conventional treatment of a ruptured tuberculous pseudoaneurysm involves surgery with graft interposition or patch repair. We report successful repair of a ruptured tuberculous pseudoaneurysm of the descending thoracic aorta by endovascular stent graft placement and provide a literature review of such entities.

An unusual combination of a tuberculous aneurysm of the thoracic aorta and a degenerative aneurysm of the infrarenal abdominal aorta.

Tuberculous aneurysms of the aorta are rare and give rise to various issues related to their diagnosis and treatment. In this article, we report on an exceptional case concerning a patient who presented with a false tuberculous aneurysm of the thoracic aorta and a degenerative aneurysm of the infrarenal abdominal aorta concomitantly. A discussion on how we approached the diagnosis and devised a therapeutic strategy that allowed us to treat this dual aortic disease effectively has also been provided. The discussion includes details of the order of treatment and the choice between an endovascular and a surgical approach.

Tuberculous pseudoaneurysm of the descending thoracic aorta.

Tuberculous mycotic aortic aneurysm is a rare disease with a high mortality rate.(1-5) Its prevalent location is the descending thoracic aorta in the patient with disseminated tuberculosis. Most of these aneurysms have been of the pseudoaneurysm type. We report the case of a 37-year-old woman with tuberculous pseudoaneurym of the descending aorta that was initially mistaken for a lung lesion and was successfully repaired surgically.

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.

Multiple mycotic aneurysms due to Mycobacterium bovis after intravesical bacillus Calmette-Guérin therapy.

Mycotic aneurysms are exceptional complications after intravesical instillations of bacillus Calmette-Guérin (BCG) for bladder carcinoma. We report a patient who underwent an emergency operation for a ruptured carotid aneurysm 16 months after BCG therapy. Postoperative investigations discovered multiple other synchronous aneurysms. Culture of an abscess surrounding the right carotid artery identified Mycobacterium bovis var BCG. The patient improved clinically with antituberculous agents prescribed for 9 months but died from recurrence of bladder carcinoma 16 months later. A mycotic origin should be evoked when an aneurysm is discovered after BCG therapy. Microbiologic investigation of the artery wall is diagnostic.

Tuberculous aneurysms of the abdominal aorta.

Mycotic aneurysm secondary to tuberculous infection of the aorta is a rare and life-threatening disease. We report a single-center experience of three patients treated with a combination of surgical aortic replacement and prolonged antituberculosis therapy. The first case is a 34-year-old woman with a suprarenal abdominal aortic aneurysm, the second case is a 77-year-old man with an infrarenal abdominal aortic aneurysm and a right psoas abscess, the third case is a 37-year-old woman with an infrarenal abdominal aortic aneurysm. All patients had a favorable outcome with a mean follow-up of 6.2 years (range, 6 months-10 years). Early diagnosis and a combination of surgical intervention (aortic reconstruction and extensive excision of the infected field) and prolonged antituberculous drug therapy provide long-term survival without evidence of recurrence after tuberculous aortic involvement.

Primary aortoduodenal fistula caused by tuberculous aortitis presenting as recurrent massive gastrointestinal bleeding.

Upper gastrointestinal bleeding from primary aortoduodenal fistula (PADF) is unusual and fatal. The etiology of PADF from tuberculous aortitis is rare. We report a 69-year-old male patient who suffered recurrent hematemesis and hematochezia with hypovolemic shock of unknown origin. Initial endoscopy failed to lead to a diagnosis. A bleeder over the third portion of the duodenum was found after the third endoscopy. Exploratory laparotomy showed a ruptured aortic pseudoaneurysm with an aortoduodenal fistula. Dacron graft repair of the aorta and simple closure of the duodenal fistula were carried out. Pathologic examination revealed tuberculous aortitis. The patient survived and was symptom-free following operation and antituberculous therapy. Review of the literature revealed that the clinical presentations in this disorder are insidious. The endoscopic findings are atypical. We conclude that so-called "herald bleeding", a history of tuberculous infection or aortic aneurysm and a high degree of suspicion are critical for successful diagnosis. Early diagnosis and surgical exploration are needed for timely and successful management.

Endovascular treatment of a tuberculous infected aneurysm of the descending thoracic aorta: a word of caution.

An infected aneurysm of the thoracic aorta due to mycobacterium tuberculosis is an unusual entity for which the classical treatment is antituberculosis chemotherapy and open-chest surgery. Recent improvements in endovascular treatments have led to their proposed use for infected aneurysms in patients for whom open surgery poses too high a risk. We report on a 68-year-old man with a tuberculous aortic aneurysm who had been treated with an endoprosthesis and antituberculosis chemotherapy. His clinical and radiological follow-up was uneventful and led to the discontinuation of pharmacological treatment after 16 months. However, a recurrence of the infection led to a fatal aortic rupture 4 months after discontinuation of therapy.

Ruptured mycotic abdominal aortic aneurysm secondary to Mycobacterium bovis after intravesical treatment with bacillus Calmette-Guérin.

Bacillus Calmette-Guérin (BCG) is a live attenuated strain of Mycobacterium bovis that has proven effective in the treatment of early-stage bladder cancer. Although intravesical therapy with BCG is generally considered safe, serious complications including hematuria, granulomatous pneumonitis, hepatitis, and life-threatening BCG sepsis are well known. BCG-related vascular infections are rarely reported. We present a case of a ruptured abdominal aortic aneurysm secondary to M bovis infection 2 years after intravesical instillation of BCG and review the related literature.

Tuberculous pericardial effusion after coronary artery bypass graft.

We describe a case of a recurrent pericardial effusion after coronary artery bypass grafting. This was initially considered to be due to post-pericardiotomy syndrome, but was later treated empirically as tuberculosis. After definitive surgery for this condition, pericardial histology and immunohistochemistry confirmed the diagnosis of tubercular pericarditis. At 4-months follow-up, while continuing anti-tuberculous therapy and corticosteroids, the patient showed consistent improvement without further recurrence of his pericardial effusion. Local reactivation of tuberculosis after pericardiotomy has not been previously reported and merits careful consideration in population groups in which tuberculosis is highly endemic.

Aortobifemoral graft infection with Mycobacterium tuberculosis: treatment with abscess drainage, debridement, and long-term administration of antibiotic agents.

Aortic graft infection with Mycobacterium tuberculosis is rare. We report a patient with a Dacron aortobifemoral prosthetic graft infection secondary to tuberculosis. The infection was successfully treated with surgical drainage without removal of the graft, and long-term antimycobacterial medications. A review of the literature contains only 1 other report of tuberculosis graft infection and treatment. We discuss a rare form of aortic graft infection from M tuberculosis and its treatment.

Tuberculous aneurysm of the supraceliac aorta--a case report.

Significant vascular complications are rare following systemic infections with Mycobacterium tuberculosis (TB). This report describes a 33-year-old man who presented with a short history of abdominal discomfort and febrile episodes with no prior history of infection with TB. Ultrasound, CT scan, and aortography confirmed the presence of a pseudoaneurysm originating from the posterior aspect of the supraceliac aorta at the level of the diaphragm. Via a full thoracoabdominal approach, periaortic inflammatory tissue and the aortic wall itself were debrided, and repair of the pseudoaneurysm was achieved with a synthetic patch. Mycobacterium tuberculosis was isolated from the aortic wall, and anti-TB medications were instituted. Postoperatively the patient did well and was discharged after 14 days. As illustrated by this case, tuberculous mycotic aneurysms of the aorta are optimally treated with a combination of medical and surgical therapy, and early diagnosis is essential to ensure survival.

Tuberculous pseudoaneurysm of the descending thoracic aorta: successful treatment by surgical excision and primary repair.

Tuberculous pseudoaneurysm of the aorta is a rare disease with a high mortality rate. We present the case of a 27-year-old woman who had a tuberculous pseudoaneurysm of the descending thoracic aorta. The patient underwent successful excision and primary repair of the lesion while under hypothermic circulatory arrest and partial femoral bypass. To the best of our knowledge, this is the youngest patient to be successfully treated with surgery for a tuberculous pseudoaneurysm of the descending thoracic aorta. The pathogenesis, diagnosis, and treatment of this disease are reviewed, and the need to include tuberculous pseudoaneurysm in the differential diagnosis of chest lesions is emphasized.