Management of patients with myocardial tuberculosis: A case series

Myocarditis with concomitant tuberculosis infection presenting with solitary ventricular tachycardia: a case report

Background

Myocarditis is an infrequent extrapulmonary manifestation of tuberculosis that confers an unfavourable prognosis.

Case summary

A 36-year-old man presented to the hospital with palpitations and dyspnoea. Tests revealed the presence of non-sustained ventricular tachycardia, with mild elevation of troponin and C-reactive protein levels. Coronary angiography showed normal results. A cardiac magnetic resonance (CMR) showed moderate hypertrophy, preserved ejection fraction, and an extensive multi-segmental pattern of fibrosis and oedema. An 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET-CT) scan revealed multiple hypermetabolic adenopathies and patchy cardiac uptake. A tuberculin skin test and interferon-gamma release assay were both positive. An endomyocardial biopsy (EMB) showed inflammation without granulomas; and microbiological stains were negative. Biopsy of an adenopathy revealed the presence of multiple necrotizing granulomas with Langhans cells. Based on the test results and clinical presentation, the suspected diagnosis was tuberculous myocarditis. Treatment with anti-tuberculosis drugs was started. One month later, the presence of mycobacterium tuberculosis (MT) was detected in the lymph node culture. At 7 months of follow-up, the patient remains asymptomatic, ventricular arrhythmias have ceased, and radiological signs of inflammation have resolved.

Discussion

Ventricular arrhythmia is one of the clinical manifestations of tuberculous myocarditis. Cardiac magnetic resonance and 18F-FDG-PET-CT imaging are an essential component of the non-invasive evaluation of inflammatory cardiomyopathy. However, a confirmatory biopsy may be required to identify potentially treatable aetiologies. Although the diagnosis of tuberculous myocarditis requires an isolation of MT by staining or culture in EMB, the diagnostic yield is very low. For this reason, extra-cardiac findings may provide the definitive diagnostic clue.

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.

Musculoskeletal Tuberculosis: New Insights on Diagnosis Strategy and Treatment

BACKGROUND/ OBJECTIVE

Skeletal tuberculosis (TB) is rare. We aimed to report on diagnostic strategy and treatment of skeletal TB.

METHODS

In this multidisciplinary single-center medical records review study, all adult patients admitted between January 2009 and December 2019 with microbiologically proven skeletal TB were included. Demographic, medical history, laboratory, imaging, pathologic findings, treatment, and follow-up data were extracted from medical records.

RESULTS

Among 184 patients identified with TB, 21 (16 women, 42 years [27, 48 years]) had skeletal involvement. Skeletal TB included spondylitis (n = 11), lytic bone lesions (n = 7), sacroiliitis (n = 5), arthritis (n = 3), osteitis (n = 2), and diffuse muscle abscesses without bone lesion (n = 1). Lytic lesions involved both axial and peripheral skeleton at multiple sites in most cases. 18F-fluorodeoxyglucose positron emission tomography was performed in 13 patients and helped to detect multifocal asymptomatic lesions and to target biopsy. All patients were treated with anti-TB therapy for 7 to 18 months. Fifteen patients (71.4%) received steroids as an adjunct therapy. Eleven patients needed an orthopedic immobilization corset, and 3 patients underwent surgery. All patients clinically improved under treatment, but 2 relapsed over a median follow-up of 24 months (12-30 months). No patient died or suffered long-term disabilities.

CONCLUSION

Our study emphasizes the diversity of skeletal involvement in TB. 18F-fluorodeoxyglucose positron emission tomography scanner at diagnosis is key to assess the extension of skeletal involvement and guide extraskeletal biopsy. Neurological complications might be prevented by adding corticosteroids to anti-TB therapy.

Diagnosis and staging of cardiac masses: additional value of CMR with 18F-FDG-PET compared to CMR with CECT

PURPOSE

Characterization of malignant cardiac masses is usually performed with cardiac magnetic resonance (CMR) and staging with whole-body contrast-enhanced computed tomography (CECT). In this study, our objective was to evaluate the role of ¹⁸Fluor-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) with CMR for both characterization and staging of cardiac masses.

METHODS

Patients with cardiac masses who underwent CMR, CECT, and ¹⁸F-FDG-PET were retrospectively identified. For the characterization of cardiac masses, we calculated the respective performances of CMR alone, ¹⁸F-FDG-PET alone, and the combination of ¹⁸F-FDG-PET and CMR. For staging, we compared head-to-head the respective performances of ¹⁸F-FDG-PET and CECT. Histology served as gold standard for malignancy, and response to anticoagulation for thrombus.

RESULTS

In a total of 28 patients (median age 60.5 years, 60.7% women), CMR accurately distinguished malignant from benign masses with sensitivity (Se) of 86.7%, specificity (Sp) of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 86.7%, and accuracy of 92.9%. ¹⁸F-FDG-PET demonstrated 93.3% Se, 84.6% Sp, 87.5% PPV, 91.7% NPV, and 89.3% accuracy. Combining CMR with ¹⁸F-FDG-PET allowed to benefit from the high sensitivity of ¹⁸F-FDG-PET (92.9%) and the excellent specificity of CMR (100%) for malignant diseases. For staging, ¹⁸F-FDG-PET outperformed CECT on per-patient (66.7% vs 55.6% correct diagnosis, respectively), per-organ (10 vs 7 organs, respectively), and per-lesion basis (> 29 vs > 25 lesions, respectively).

CONCLUSION

Combining ¹⁸F-FDG-PET with CMR improved the characterization of cardiac masses compared to each modality alone. Additionally, the diagnostic performance of ¹⁸F-FDG-PET was better than CECT for staging. This study suggests that the combination of CMR and ¹⁸F-FDG-PET is the most effective for the characterization of cardiac masses and the staging of these lesions.