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Murillo Moreno MA, López Gutiérrez LV, Vinck EE, Roncancio Villamil G, Gallego Muñoz C, Saldarriaga Giraldo CI. Coronary heart disease and tuberculosis: an unnoticed syndemia. Review of literature and management proposal. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2024; 5:e375. [PMID: 39015190 PMCID: PMC11247974 DOI: 10.47487/apcyccv.v5i2.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/03/2024] [Indexed: 07/18/2024]
Abstract
Tuberculosis is an increasing disease that affects about one-third of the global population. In line with the rise of tuberculosis, cardiovascular disease has shown a similar trend, with ischemic coronary heart disease becoming the leading cause of death worldwide. Based on the literature, a relationship can be drawn between tuberculosis and ischemic coronary heart disease through their shared multiple risk factors and a possible pathophysiological substrate linking them. The presentation of these two conditions reported so far is varied: it has been found as the onset of acute coronary syndrome in patients with active tuberculosis, the progressive development of coronary atherosclerosis in patients with latent tuberculosis, among others. Given this possible link and the progressive increase in their incidence rates, we can assert that we are facing an unnoticed syndemic, with their concurrent management posing a challenge due to significant pharmacological interactions. The purpose of this review is to clarify this possible link, propose an approach for diagnosis, and provide a treatment algorithm for the entire spectrum of coronary disease coexisting with tuberculosis according to the current available literature.
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Affiliation(s)
- Mauricio Andrés Murillo Moreno
- Departamento de Medicina Interna, Universidad CES, Medellín, Colombia.Universidad CESDepartamento de Medicina InternaUniversidad CESMedellínColombia
| | - Laura Valentina López Gutiérrez
- Departamento de Cardiología, Clínica Cardio VID, Medellín, Colombia.Departamento de CardiologíaClínica Cardio VIDMedellínColombia
| | - Eric Edward Vinck
- Departamento de Cirugía Cardiovascular, Clínica Cardio VID, Medellín, Colombia.Departamento de Cirugía CardiovascularClínica Cardio VIDMedellínColombia
| | - Gustavo Roncancio Villamil
- Departamento de Enfermedades Infecciosas, Clínica Cardio VID, Medellín, Colombia.Departamento de Enfermedades InfecciosasClínica Cardio VIDMedellínColombia
| | - Catalina Gallego Muñoz
- Departamento de Cardiología, Clínica Cardio VID, Medellín, Colombia.Departamento de CardiologíaClínica Cardio VIDMedellínColombia
| | - Clara Inés Saldarriaga Giraldo
- Departamento de Cardiología, Clínica Cardio VID, Medellín, Colombia.Departamento de CardiologíaClínica Cardio VIDMedellínColombia
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Hamada K, Oishi K, Uehara S, Suetake R, Yamaji Y, Asami-Noyama M, Edakuni N, Hirano T, Sakamoto K, Matsumoto T, Matsunaga K. Deep Sternal Wound Tuberculosis with Hypo-gamma-globulinemia. Intern Med 2018; 57:2563-2566. [PMID: 29709943 PMCID: PMC6172533 DOI: 10.2169/internalmedicine.0617-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 44-year-old man was referred to our hospital for the treatment of a pulmonary and deep sternal wound tuberculosis infection, which is an extremely rare type of extrapulmonary tuberculosis. Laboratory testing revealed a serum immunoglobulin (Ig) G level of 286 mg/dL, IgA of 22 mg/dL and IgM of 13 mg/dL. We therefore diagnosed him with hypo-gamma-globulinemia. He was treated with anti-tuberculosis medications and intravenous immunoglobulin. At present, the tuberculosis has not relapsed in the past six years. It may be useful to assess the humoral immunity status in tuberculosis patients with a normal T cell function, and immunoglobulin therapy may be beneficial for protecting such patients from reactivation of tuberculosis.
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Affiliation(s)
- Kazuki Hamada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Keiji Oishi
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
- Division of Cardiology, Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Japan
| | - Sho Uehara
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Ryo Suetake
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Yoshikazu Yamaji
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Nobutaka Edakuni
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
| | - Kenji Sakamoto
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
- Department of Respiratory Medicine, Yamaguchi-Ube Medical Center, Japan
| | - Tsuneo Matsumoto
- Department of Respiratory Medicine, Yamaguchi-Ube Medical Center, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Japan
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Tabaja H, Hajar Z, Kanj SS. A review of eleven cases of tuberculosis presenting as sternal wound abscess after open heart surgery. Infect Dis (Lond) 2017; 49:721-727. [PMID: 28687049 DOI: 10.1080/23744235.2017.1347817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Sternal wound infection with Mycobacterium tuberculosis is an uncommon yet highly challenging disease that can be quite insidious with various presentations. We hereby provide a review of 10 cases in current literature and describe an additional case which illustrates the difficulties associated with diagnosis. METHODS We used PubMed and Google search engine to search the literature for all published papers reporting on cases of sternal M. tuberculosis infections post open-heart surgeries. RESULTS A total of 11 cases were presented, including a case of our own. The majority were males and were exposed to endemic areas. The average age was 59.6 ± 15.5 years. Coronary artery bypass surgery accounted for 73% of procedures and the average time to symptoms onset was 12.2 ± 16.6 months. Diabetes was the most reported non-cardiac comorbidity. Presenting symptoms varied and only 5 patients had other organs involved. Blood tests and radiographic studies were neither sensitive nor specific. M. tuberculosis culture on debrided tissues was the most sensitive test but often forgotten initially. Diagnostic delay was seen in almost all cases, often leading to unnecessary courses of antibiotics and aggressive surgical interventions. Finally, all patients responded well to anti-tuberculosis treatment, with reported treatment duration ranging from 9 to 12 months. CONCLUSION M. tuberculosis infection of the sternum should be suspected in late-onset sternal wound infections post open-heart surgery especially when the course is chronic and indolent.
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Affiliation(s)
- Hussam Tabaja
- a Department of Internal Medicine, Division of Infectious Diseases , American University of Beirut Medical Center , Beirut , Lebanon
| | - Zeina Hajar
- a Department of Internal Medicine, Division of Infectious Diseases , American University of Beirut Medical Center , Beirut , Lebanon
| | - Souha S Kanj
- a Department of Internal Medicine, Division of Infectious Diseases , American University of Beirut Medical Center , Beirut , Lebanon
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Grover SB, Arora S, Kumar A, Grover H, Katyan A, Nair DM. "Caught by the Eye of Sound" - Epigastric Swelling due to Xiphisternal Tuberculosis. Pol J Radiol 2017; 82:41-45. [PMID: 28217237 PMCID: PMC5292989 DOI: 10.12659/pjr.899329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/06/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Common causes of an epigastric mass include hepatomegaly, pancreatic pseudocyst and epigastric hernia, less common causes being carcinoma of the stomach or pancreas, whereas diseases of the sternum presenting as an epigastric swelling is extremely uncommon. We report a case of tubercular infection of the sternum located in the xiphoid process resulting in its presentation as an epigastric swelling. CASE REPORT A 30-year-old immunocompetent woman with complaints of an epigastric swelling and undocumented pyrexia for four months was referred for sonographic evaluation with a clinical suspicion of an incompletely treated liver abscess. The patient was examined with ultrasound, sternal radiographs, CT and MRI. Ultrasound revealed a heterogeneous epigastric collection with linear echogenic components suggestive of bone fragments. These appearances suggested chronic infective osteomyelitis of the xiphoid process of the sternum. Lateral chest radiograph demonstrated lytic destruction of the xiphisternum. Tubercular etiology was considered and further evaluation with Multidetector Computed tomography (MDCT) and Magnetic Resonance Imaging (MRI) demonstrated erosive osteomyelitis of the xiphoid process with enhancing inflammation and collection in the adjoining soft tissue. Ultrasound-guided aspiration, PCR and Amplified Mycobacterium tuberculosis DNA test confirmed tubercular infection. CONCLUSIONS We report a new case of osteo-articular tuberculosis localized to the xiphisternum, a rare clinical entity with an extremely unusual clinical presentation as an epigastric mass. The role of ultrasound in primary diagnosis and as an interventional diagnostic modality for guided aspiration is highlighted.
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Affiliation(s)
- Shabnam Bhandari Grover
- Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sumit Arora
- At the time of study: Department of Orthopaedic Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India; Presently, Department of Orthopaedic Surgery, Maulana Azad Medical College, New Delhi, India
| | - Amit Kumar
- At the time of study: Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India; Presently: MR Centre, Green Park, New Delhi, India
| | - Hemal Grover
- At time of study: Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Deputed from Institute of Nuclear Medicine and Allied Sciences, Delhi, India; Currently, Department of Neuro Radiology, New York Medical University, New York, NY, U.S.A
| | - Amit Katyan
- Department of Radiology and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Deepthi Mohan Nair
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Abstract
Sternal mycobacterial infections are rare. Due to the rarity, its clinical characteristics, diagnoses, and regular management strategies are still scanty. A total of 76 articles on this topic were obtained by a comprehensive literature collection. The clinical features, diagnosis, management strategies and prognosis were carefully analyzed. There were totally 159 patients including 152 (95%) cases of tuberculosis (TB) and seven (5%) cases of non-TB sternal infections. Sternal mycobacterial infections can be categorized into three types: Primary, secondary, and postoperative, according to the pathogenesis; and categorized into isolated, peristernal, and multifocal, according to the extent of the lesions. Microbiological investigation is more sensitive than medical imaging and Mantoux tuberculin skin test in the diagnosis of sternal infections. Most patients show good responses to the standard four-drug regimen and a surgical intervention was necessary in 28.3% patients. The prognoses of the patients are good with a very low mortality. A delayed diagnosis of sternal mycobacterial infections may bring about recurrent sternal infections and sustained incurability. An early diagnosis and prompt antibiotic regimens may significantly improve the patients' outcomes.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China
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6
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Yuan SM. Sternal wound tuberculosis following cardiac operations: a review. Braz J Cardiovasc Surg 2016; 30:489-93. [PMID: 27163424 PMCID: PMC4614933 DOI: 10.5935/1678-9741.20140102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/04/2014] [Indexed: 11/20/2022] Open
Abstract
Objective The diagnosis and treatment of sternal wound infections with mycobacteria are
challenging. Such an infection is often associated with a delayed diagnosis
and improper treatment that may lead to a worsened clinical outcome. The
present study is designed to highlight its clinical features so as to
facilitate a prompt diagnosis and timely treatment. Methods MEDLINE, Highwire Press, and Google search engine were searched for
publications in the English language, with no time limit, reporting on
sternal wound infection caused by tuberculosis after cardiac surgery. Results A total of 12 articles reporting on 14 patients were included in this study.
Coronary artery bypass grafting was the underlying surgical procedure in
more than half of the cases. Purulent discharge and cold abscess were the
two main presenting symptoms. Diagnosis of sternal wound infection was
evidenced in all 14 patients by different investigations, with culture of
samples being the most sensitive method of identifying the pathogen. Good
response to first-line anti-tuberculous agents was noted. Almost all
patients required surgical debridement/resection and, sometimes, sternal
reconstruction. A delayed diagnosis of sternal wound infection may lead to
repeated recurrences. A comparison between patients with sternal wound
infection due to tuberculosis and non-tuberculous mycobacterial infections
showed that the former infections took an even longer period of time.
Comparisons also revealed patients with sternal tuberculosis infection had a
significantly higher mortality than patients with sternal non-tuberculous
infection (29.2% vs. 0%, P=0.051). Conclusion Sternal infection caused by tuberculosis after cardiac surgery has a longer
latency, better response to first-line drugs, and better outcomes in
comparison with non-tuberculous sternal infection. Early diagnosis and early
anti-tuberculous treatment can surely improve the patients' prognosis.
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Affiliation(s)
- Shi-Min Yuan
- Teaching Hospital, Fujian Medical University, Putian, China
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8
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Kim HJ, Kim JB, Chung CH. Chronic Sternum Wound Infection Caused by Mycobacterium tuberculosis After Cardiac Surgery. Ann Thorac Surg 2012; 94:1332-5. [DOI: 10.1016/j.athoracsur.2012.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/15/2012] [Accepted: 02/02/2012] [Indexed: 11/26/2022]
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Hegazi A, Dragovic B. Tuberculous osteomyelitis of the sternum in a patient with well controlled HIV infection and undetectable vitamin D levels. HIV & AIDS REVIEW 2012. [DOI: 10.1016/j.hivar.2012.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Singal R, Singh P, Mittal A, Gupta S, Singla S, Kenwar DB. Primary sternal tuberculous ulcer with dissemination to the bone marrow: a clinical rarity. Ann Saudi Med 2011; 31:542-5. [PMID: 21911997 PMCID: PMC3183694 DOI: 10.4103/0256-4947.84642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary tubercular osteomyelitis of the sternum with dissemination to bone marrow is a rarely described entity even in countries where tuberculosis is endemic. Delayed presentations can be in the form of sinus formation, spontaneous fracture of the sternum, extrasternal spread, and sepsis. Diagnosis can be made by CT of the chest wall and Ziehl-Neelsen staining of aspirate from the lesion or by tissue biopsy. We present a case of tuberculous osteomyelitis of the sternum with sinus formation along with widespread involvement of bone marrow, which was successfully treated with antituberculous therapy. Sternal osteomyelitis is difficult to diagnose on chest radiography and ultrasonography, but we were able to make the probable diagnosis of sternal tuberculous osteomyelitis. CT showed erosion of part of the sternal bone. Diagnosis was confirmed on histopathology and by bone marrow trephine biopsy. During the follow-up period of 3 months, the patient showed a satisfactory response to treatment.
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Affiliation(s)
- Rikki Singal
- From the Department of Surgery, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana Ambala, Haryana, India
| | - Prem Singh
- Department of Pathology, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana Ambala, Haryana, India
| | - Amit Mittal
- Department of Radiodiagnosis, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana Ambala, Haryana, India
| | - Samita Gupta
- Department of Radiodiagnosis, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana Ambala, Haryana, India
| | - Shveta Singla
- Department of Pathology, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana Ambala, Haryana, India
| | - Deepesh Benjamin Kenwar
- From the Department of Surgery, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana Ambala, Haryana, India
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Sternal Osteomyelitis Caused by Mycobacterium tuberculosis After Open Heart Surgery. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e31820428cc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Primary sternal tuberculosis osteomyelitis: A case report and discussion. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 20:e181-4. [PMID: 21119799 DOI: 10.1155/2009/484712] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As immigration to the United States from countries endemic for tuberculosis (TB) increases, the incidence of pulmonary and extrapulmonary TB disease may increase. Primary tuberculous sternal osteomyelitis is one form of extrapulmonary TB that is exceedingly rare throughout the world, and falls under the differential diagnosis for chest wall masses. Management involves standard antituberculous therapy with antibiotics similar to treating other forms of extrapulmonary TB, as well as consideration of surgical intervention depending on the extent of osteomyelitis. A typical case of primary sternal TB osteomyelitis is reported, and the epidemiology, differential diagnosis, clinical manifestations and management are reviewed.
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Sternal wound infection following open heart surgery: appraisal of incidence, risk factors, changing bacteriologic pattern and treatment outcome. Indian J Thorac Cardiovasc Surg 2011. [DOI: 10.1007/s12055-011-0081-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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de Carli DM, Severo MD, Haygert CJP, Guollo M, Omairi A, Pedro VD, Silva EP, Rodrigues AT. Sternal osteomyelitis caused by infection with Mycobacterium tuberculosis. J Bras Pneumol 2010; 35:709-12. [PMID: 19669010 DOI: 10.1590/s1806-37132009000700013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 01/12/2009] [Indexed: 11/21/2022] Open
Abstract
We report the case of a 74-year-old male patient with a one-year history of chest pain in the suprasternal notch associated with erythema, edema and drainage of purulent material from a fistulous lesion. The patient was HIV-negative with no history of TB. A CT scan of the chest showed an osteolytic lesion in the sternum, and a biopsy revealed caseous granuloma, which, in the microbiological evaluation, was negative for fungi and acid-fast bacilli. The diagnosis of sternal osteomyelitis caused by Mycobacterium tuberculosis was confirmed using PCR.
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