Tuberculous aneurysm diagnosed by CT-Guided biopsy after stent graft replacement: A case report.

A tuberculous aneurysm is an uncommon extrapulmonary tuberculosis and is usually fatal. The best way to treat it involves a combination of open surgery and medical treatment. However, it can be challenging to diagnose a tuberculous aneurysm. In this report, we describe a patient with a tuberculous aneurysm who was treated with stent-graft replacement and CT-guided biopsy for diagnosis, followed by nine months of anti-tuberculosis therapy. Despite one week of anti-tuberculous therapy, her fever persisted. A CT scan revealed new, well-defined nodules measuring 1-2mm in the lungs and hepatomegaly, indicating complications of miliary tuberculosis. After three weeks after the CT-guided biopsy, Mycobacterium tuberculosis grew from the arterial wall tissue, leading to the diagnosis of a tuberculous aneurysm complicated by miliary tuberculosis. The patient's aneurysm disappeared on follow-up CT scans, and the patient has been under observation for five years without a relapse. This rare case of tuberculous aneurysm can provide lessons for countries with a low prevalence of tuberculosis. This suggests the possibility of treatment with stent-graft replacement and anti-tuberculous medication and the usefulness of CT-guided biopsy for microbiological and pathological diagnosis.

Life-threatening ventricular arrhythmia as first presentation of Tuberculosis-Early diagnosis and successful treatment: A case series.

BACKGROUND: Tuberculosis of the myocardium is an extremely rare entity with few published case reports. Diagnosis is often delayed, and outcomes are unfavorable: particularly when cardiac involvement has been the presenting entity. METHODS: Four patients, aged 24-51 years, presented with life-threatening ventricular arrhythmia (VA). None had a previous history of tuberculosis or any structural heart disease. Electrocardiogram during sinus rhythm and Echocardiography did not show any gross abnormality. All patients underwent contrast-enhanced computer tomography of thorax and cardiac magnetic resonance imaging. Attempts to obtain tissue (cardiac or associated mediastinal lymph nodes) were associated with increased risk to the patients thus indirect evidence of Mantoux skin test and interferon gamma release assay results were used to aid diagnosis. RESULTS: Based on clinicoradiological findings, patients were put on antitubercular therapy (ATT). Supportive therapy included antiarrhythmic drugs (all patients), catheter ablation (two patients), and implantable cardioverter defibrillator (one patient). Arrhythmia suppression was achieved in all patients predischarge. On a follow-up of 2-24 months, none of the patients has had any recurrence of arrhythmia. ATT and antiarrhythmic drug therapy have been stopped in two patients who have completed the 6 months of ATT. Their radiological lesions showed resolution. CONCLUSIONS: Myocardial tuberculosis presenting as life-threatening VA in a rare but definite clinical entity. A high index of suspicion and cardiac imaging can lead to early diagnosis and appropriate treatment that ensures survival in all patients.

An unusual case of mycobacterium tuberculous coronary arteritis and thrombosis resulting in acute myocardial infarction.

Tuberculosis (TB) is a prevalent infection worldwide and an endemic infection in Singapore. The most common presentation is that of pulmonary tuberculosis. Extra pulmonary tuberculosis usually involves the lymph nodes, pleura, central nervous system, or abdominal cavity. Involvement of the heart is rare (0.14-2% of TB cases), and when it is involved, it tends to be in the pericardium or myocardium. Here, a rare case of sudden death due to tuberculous coronary arteritis with tuberculous coronary thrombosis resulting in acute myocardial infarction is presented.

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.

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.

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.

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.

Intracardiac left atrial tuberculoma in an eleven-month-old infant: case report.

BACKGROUND: Cardiac tuberculosis is rare and usually manifests as tuberculous pericarditis. Involvement of other part of the heart is unusual and descriptions in the pediatric literature are confined to few case reports regarding mainly myocardial tuberculosis. CASE PRESENTATION: We describe a case of pulmonary miliary tuberculosis associated with intracardiac left atrial tuberculoma in an immunocompetent eleven-month-old infant successfully treated with surgery and antituberculous therapy. CONCLUSION: Although unusual, involvement of endocardium in disseminated tuberculosis should be kept in mind.

Cardiac tuberculoma of the right atrium.

We report a patient with a large mass in the right atrium with tricuspid valve involvement resulting in significant stenosis, which was a tuberculoma without active pulmonary disease. Cardiac tuberculoma is rare and usually involves the pericardium. Myocardial involvement is a very rare occurrence.

It's aneurysmal, it's stenotic, it's tuberculosis.

Tuberculous vasculitis is a very rare presentation of tuberculosis. So far this is the second reported case in the literature. The diagnosis of this disorder is based on the clinical presentation as well as blood investigation results. With the ever improvement in modern medicine and improvement in endovascular treatment of such diseases, the morbidity and mortality of these patients have been dramatically reduced with better clinical and survival results. We present a case of endovascular stenting of a stenotic subclavian artery with good results.

Preliminary investigation of the clinical value of vascular endothelial growth factor and hypoxia-inducible factor-1alpha in pericardial fluid in diagnosing malignant and tuberculous pericardial effusion.

OBJECTIVES: To investigate the clinical value of vascular endothelial growth factor (VEGF) and hypoxia-inducible factor-1alpha (HIF-1alpha) in diagnosing malignant and tuberculous pericardial effusion. METHODS: Eighty patients with exudative pericardial effusion undergoing pericardiocentesis and drainage were divided into 2 groups, namely those with malignancy and those with tuberculosis. The levels of HIF-1alpha, VEGF, lactate dehydrogenase (LDH) and adenosine deaminase (ADA) in pericardial fluid and serum were measured. Routine and cytological examination of pericardial fluid, clinical characteristics and some blood parameters were compared between the 2 groups. RESULTS: There were 33 patients with tuberculous pericardial effusion and 47 with malignant pericardial effusion. The levels of VEGF and HIF-1alpha in pericardial fluid in the malignancy group were significantly higher than those in the tuberculosis group (p < 0.01), and there was a moderate positive correlation between the levels of VEGF and HIF-1alpha (r = 0.79, p < 0.01). The sensitivity and specificity of combining VEGF and HIF-1alpha were 90.8 and 88.3%, respectively. The 2 groups showed no differences with regard to gender distribution, occurrence of fever, erythrocyte sedimentation rate or the levels of hemoglobin, LDH, ADA, serum HIF-1alpha and VEGF. CONCLUSIONS: Both VEGF and HIF-1alpha in pericardial fluid have determinative value in the differential diagnosis of malignant and tuberculous pericardial effusion.

Obstructing Granuloma in Main Pulmonary Trunk.

A patient with main pulmonary artery mass may have severe symptoms and warrants urgent surgical management, whereas in a stable patient with a diagnosis amenable to medical treatment, medical management should be started while monitoring the size of the lesion. We report a case in which the patient experienced severe right heart dysfunction due to obstruction of the main pulmonary artery, diagnosed as a probable thrombus, and the patient was taken for urgent surgical excision, later diagnosed as tuberculoma on histopathologic examination.

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.

[Tuberculous aneurysm of abdominal aorta: case report and literature review]. / Anévrisme tuberculeux de l'aorte abdominale: cas clinique et revue de la littérature.

Tuberculous aneurysms of aorta are rare. They expose to a very high risk of unpredictable rupture with serious hemodynamic consequences. We report a 82-year-old male who presented with an tuberculous aortic aneurysm in a prerupture state. He underwent a surgical treatment and antibiotic therapy. Postoperative course was uneventful. Epidemiology, pathogenesis, presentation, management and mortality of this affection were reviewed and discussed. With appropriate medical and surgical management, the prognosis of this infection is very good.

Increased Diagnostic Yield of Tuberculous Serositis by Using Serous Fluid Drainage Flocky Precipitate (SFDFP) as a Testing Sample.

A definitive diagnosis of tuberculosis serositis (TS) is still challenging. Our preliminary practice found that Serous Fluid Drainage Flocky Precipitate (SFDFP) was a useful testing sample to diagnose TS. We designed this study to assess the diagnostic performance of SFDPF for TS compared with conventional bacteriology methods on serous fluid (SF). A cohort study was conducted from July 2014 to April 2016. Patients with suspected TS were consecutively screened. SF and SFDFP were collected and tested by Ziehl-Neelsen stain, MTB culture, and Xpert/RIF assay. We compared the diagnostic performance of SF and SFDFP in several test settings. Through this study, 85 patients were enrolled, of whom 70 (82.4%) were confirmed TS or highly probable TS, 13 (15.3%) were none-TS and 2 (2.4%) indeterminate results were ruled out. The overall sensitivity using both SFDFP and SF was significantly higher than each (60% vs. 48% and 41%, p < 0.05). SFDFP and SF samples had similar diagnostic performance (p < 0.05). No false positive was detected in this study. We concluded that SFDFP is a reliable testing sample for diagnosing tuberculous serositis. SFDFP may significantly improve the diagnostic yield as a supplement to conventional tests.

[Surgical treatment of a ruptured aneurysm of the left common iliac artery in a patient with miliary tuberculosis]. / Traitement chirurgical d'un anévrisme rompu de l'artère iliaque commune gauche chez un patient présentant une tuberculose miliaire.

Tuberculous aneurysms of the common iliac artery are rare. Only a few cases have been reported in the literature. We report a new case in a 47-year-old man admitted for abdominal pain and persistent fever. The aneurysm was evoked in the duplex ultrasound scan and confirmed by computed tomographic angiography. The patient underwent an extra-anatomic femorofemoral bypass with a dacron prosthesis and ligation of the aneurysmal artery. The postoperative course was marked by febrile dyspnea related to the tuberculous miliary found on the chest x-ray. Histological analysis of the operative specimens confirmed the tuberculous origin of the aneurysm. The patient was put on antituberculous drugs and the follow-up was uneventful. With a follow-up of four months, the patient was asymptomatic and the bypass was well patent.

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.