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Tuberculosis of the Heart: A Diagnostic Challenge. Tomography 2022; 8:1649-1665. [PMID: 35894002 PMCID: PMC9326682 DOI: 10.3390/tomography8040137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis of the heart is relatively rare and presents a significant diagnostic difficulty for physicians. It is the leading cause of death from infectious illness. It is one of the top 10 leading causes of death worldwide, with a disproportionate impact in low- and middle-income nations. The radiologist plays a pivotal role as CMR is a non-invasive radiological method that can aid in identifying potential overlap and differential diagnosis between tuberculosis, mass lesions, pericarditis, and myocarditis. Regardless of similarities or overlap in observations, the combination of clinical and certain particular radiological features, which are also detected by comparison to earlier and follow-up CMR scans, may aid in the differential diagnosis. CMR offers a significant advantage over echocardiography for detecting, characterizing, and assessing cardiovascular abnormalities. In conjunction with clinical presentation, knowledge of LGE, feature tracking, and parametric imaging in CMR may help in the early detection of tuberculous myopericarditis and serve as a surrogate for endomyocardial biopsy resulting in a quicker diagnosis and therapy. This article aims to explain the current state of cardiac tuberculosis, the diagnostic utility of CMR in tuberculosis (TB) patients, and offer an overview of the various imaging and laboratory procedures used to detect cardiac tuberculosis.
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Gococo-Benore DA, McKenna AL, Harris DM. 44-Year-Old Woman With Fever, Sore Throat, and Polyarthralgia. Mayo Clin Proc 2021; 96:2708-2712. [PMID: 34531063 DOI: 10.1016/j.mayocp.2021.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/07/2021] [Accepted: 01/27/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Denise A Gococo-Benore
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Amanda L McKenna
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Dana M Harris
- Advisor to residents and Consultant in Primary Care Internal Medicine, Mayo Clinic, Jacksonville, FL.
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Makavos G, Varoudi M, Papangelopoulou K, Kapniari E, Plotas P, Ikonomidis I, Papadavid E. Echocardiography in Autoimmune Rheumatic Diseases for Diagnosis and Prognosis of Cardiovascular Complications. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:medicina56090445. [PMID: 32883041 PMCID: PMC7558642 DOI: 10.3390/medicina56090445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/23/2022]
Abstract
Autoimmune rheumatic diseases are systemic diseases frequently affecting the heart and vessels. The main cardiovascular complications are pericarditis, myocarditis, valvular disease, obstructive coronary artery disease and coronary microcirculatory dysfunction, cardiac failure and pulmonary hypertension. Echocardiography, including transthoracic two and three-dimensional echocardiography, Doppler imaging, myocardial deformation and transesophageal echo, is an established and widely available imaging technique for the identification of cardiovascular manifestations that are crucial for prognosis in rheumatic diseases. Echocardiography is also important for monitoring the impact of drug treatment on cardiac function, coronary microcirculatory function, valvular function and pulmonary artery pressures. In this article we summarize established and evolving knowledge on the role of echocardiography for diagnosis and prognosis of cardiovascular abnormalities in rheumatic diseases.
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Affiliation(s)
- George Makavos
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (M.V.); (K.P.); (P.P.); (I.I.)
- Correspondence: ; Tel.: +30-210-5832187
| | - Maria Varoudi
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (M.V.); (K.P.); (P.P.); (I.I.)
| | - Konstantina Papangelopoulou
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (M.V.); (K.P.); (P.P.); (I.I.)
| | - Eirini Kapniari
- Second Department of Dermatology and Venereology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (E.K.); (E.P.)
| | - Panagiotis Plotas
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (M.V.); (K.P.); (P.P.); (I.I.)
| | - Ignatios Ikonomidis
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (M.V.); (K.P.); (P.P.); (I.I.)
| | - Evangelia Papadavid
- Second Department of Dermatology and Venereology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (E.K.); (E.P.)
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Ikonomidis I, Makavos G, Katsimbri P, Boumpas DT, Parissis J, Iliodromitis E. Imaging Risk in Multisystem Inflammatory Diseases. JACC Cardiovasc Imaging 2019; 12:2517-2537. [DOI: 10.1016/j.jcmg.2018.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 05/29/2018] [Accepted: 06/28/2018] [Indexed: 11/17/2022]
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Atherosclerosis in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2017; 31:364-372. [PMID: 29224678 DOI: 10.1016/j.berh.2017.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/05/2017] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease (CVD), comprising coronary heart disease and stroke, is one of the most important causes of death in patients with systemic lupus erythematosus (SLE). The risks of developing both clinical CVD and sub-clinical atherosclerosis are increased in patients with SLE. This increase is not fully explained by traditional cardiovascular risk factors such as smoking, hypertension and elevated cholesterol, and it is believed that immune dysfunction also contributes to CVD risk in SLE. In particular, recent studies have shown that abnormalities in both serum lipid profile and the autoantibody and T lymphocyte response to lipids may play a role in development of atherosclerosis. The standard CVD risk calculation algorithms based on traditional risk factors underestimate the risk of developing CVD in patients with SLE. Thus, novel algorithms incorporating new biomarkers such as pro-inflammatory high-density lipoprotein and use of imaging techniques such as carotid ultrasound scanning may become increasingly valuable.
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Abstract
Cardiovascular disease is an important extra-articular manifestation of rheumatologic diseases leading to considerable mortality and morbidity. Echocardiography emerges as a useful non-invasive technique for the screening and evaluation of cardiac involvement in these patients. With the technological advancement in echocardiographic techniques, we have gained a greater appreciation of the prevalence and nature of the cardiac involvement in these patients, as detection of subclinical disease is increasingly feasible. This review discusses cardiac involvement in patients with rheumatoid arthritis, systemic lupus erythematosus, anti-phospholipid antibody syndrome, systemic sclerosis and ankylosing spondylitis, and the role of different echocardiographic modalities in their evaluation.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Kwan-Leung Chan
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, ON, Canada. .,University of Ottawa Heart Institute, 40 Ruskin Street, Room H3412, Ottawa, ON, K1Y 4W7, Canada.
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Chen J, Tang Y, Zhu M, Xu A. Heart involvement in systemic lupus erythematosus: a systemic review and meta-analysis. Clin Rheumatol 2016; 35:2437-48. [PMID: 27502777 DOI: 10.1007/s10067-016-3373-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/16/2016] [Accepted: 08/01/2016] [Indexed: 12/21/2022]
Abstract
Cardiovascular diseases are one of the most important causes of the disability and mortality in patients with systemic lupus erythematosus (SLE). The present study examined the cardiac abnormalities in patients with SLE by echocardiography. Case-control studies were obtained by searching PubMed MEDLINE, Embase, and MD Consult. Systemic review and meta-analysis were performed to assess the cardiac abnormalities based on the changes in the echocardiography in patients with SLE. Twenty-two studies including 1117 SLE patients and 901 healthy controls were enrolled into this study. We found that patients with SLE developed the pericardial effusion (odds ratio (OR) (95 % confidence interval (CI)) 30.52 (9.70-96.02); p < 0.00001) and the combined valvular alterations (OR (95 %CI) 11.08 (6.98-17.59); p < 0.00001). In addition, SLE patients also exhibited an increase in the left atrial diameter (LAD) (WMD-weighted mean difference (95 %CI) 0.18 (0.06-0.29); p = 0.002), the left ventricular internal diameter in diastole (LVDd) (WMD (95 %CI) 0.07 (0.02-0.12); p = 0.01), and the left ventricular mass index (LVMI) (WMD (95 %CI) 5.69 (2.69-8.69); p = 0.0002). In contrast, the left ventricular systolic function (WMD (95 %CI) -1.22 (-1.69 to -0.75); p < 0.00001) and diastolic function including E/A ratio and E/E' ratio (WMD (95 % CI) -0.13 (-0.24 to -0.01); p = 0.04; WMD (95 % CI) 1.71 (0.43 to 2.99); p = 0.009) were decreased in SLE patients. Patients with SLE are associated with significant alterations in cardiac structure and function as demonstrated by echocardiography. Data from this study suggest that echocardiographic assessment should be considered as a part of routine examinations for SLE patients clinically.
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Affiliation(s)
- Junzhe Chen
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-Jiang Xi Road, Guangzhou, 510120, China
| | - Ying Tang
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-Jiang Xi Road, Guangzhou, 510120, China
| | - Mingsheng Zhu
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-Jiang Xi Road, Guangzhou, 510120, China
| | - Anping Xu
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-Jiang Xi Road, Guangzhou, 510120, China.
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Hong J, Maron DJ, Shirai T, Weyand CM. Accelerated atherosclerosis in patients with chronic inflammatory rheumatologic conditions. ACTA ACUST UNITED AC 2015; 10:365-381. [PMID: 27042216 DOI: 10.2217/ijr.15.33] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Atherosclerosis is a complex inflammatory disease involving aberrant immune and tissue healing responses, which begins with endothelial dysfunction and ends with plaque development, instability and rupture. The increased risk for coronary artery disease in patients with rheumatologic diseases highlights how aberrancy in the innate and adaptive immune system may be central to development of both disease states and that atherosclerosis may be on a spectrum of immune-mediated conditions. Recognition of the tight association between chronic inflammatory disease and complications of atherosclerosis will impact the understanding of underlying pathogenic mechanisms and change diagnostic and therapeutic approaches in patients with rheumatologic syndromes as well as patients with coronary artery disease. In this review, we provide a summary of the role of the immune system in atherosclerosis, discuss the proposed mechanisms of accelerated atherosclerosis seen in association with rheumatologic diseases, evaluate the effect of immunosuppression on atherosclerosis and provide updates on available risk assessment tools, biomarkers and imaging modalities.
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Affiliation(s)
- Jison Hong
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - David J Maron
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Tsuyoshi Shirai
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Cornelia M Weyand
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
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Abstract
Although echocardiography remains the standard diagnostic tool for identifying pericardial diseases, procedures with better delineation of morphology and heart function are often required. The pericardium consists of an inner visceral (epicardium) and outer parietal layer (pericardium), which constitute for the pericardial cavity. Pericardial effusion can occur as transudate, exudate, pyopneumopericardium, or hemopericardium. Potential causes are inflammatory processes, that is, pericarditis due to autoimmune or infective reasons, neoplasms, irradiation, or systemic disorders, chronic renal failure, endocrine, or metabolic diseases. Pericardial fat can mimic pericardial effusion. Using various image-acquisition sequences, MRI allows identifying and separating fluid and solid structures. Fast spin-echo T1-weighted sequences with black-blood preparation are favourably used for morphological evaluation. Fast spin-echo T2-weighted sequences, particularly with fat saturation, and short-tau inversion-recovery sequences are useful to visualize oedema and inflammation. For further tissue characterization, delayed inversion-recovery imaging is used. Therefore, image acquisition is performed at 5-20 min subsequent to contrast agent administration, the so-called technique of late gadolinium enhancement. Ventricular volumes and myocardial mass can be assessed accurately by steady-state free-precession sequences, which is required to measure cardiac function and ventricular wall stress. Constrictive pericarditis usually results from chronic inflammatory processes leading to increased stiffness, which impedes the slippage of both pericardial layers and thereby the normal cardiac filling. CT imaging can favourably assess pericardial calcification. Thus, MR and CT imaging allow a comprehensive delineation of the pericardium. Superior to echocardiography, both methods provide a larger field of view and depiction of the complete chest including abnormalities of the surrounding mediastinum and lungs. PET provides unique information on the in vivo metabolism of 18-fluorodeoxyglucose that can be superimposed on CT findings and is useful for identifying inflammatory processes or masses, for example neoplasms. These imaging techniques provide advanced information of anatomy and cardiac function to optimize the pericardial access, for example by the AttachLifter system, for diagnosis and treatment.
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Abstract
In inflammatory dilated cardiomyopathy and myocarditis there is--apart from heart failure and antiarrhythmic therapies--no alternative to an aetiologically driven specific treatment. Prerequisite are noninvasive and invasive biomarkers including endomyocardial biopsy and PCR on cardiotropic agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy including the genetic background, the predisposition for heart failure and inflammation. It analyses the epidemiologic shift in pathogenetic agents in the last 20 years, the role of innate and aquired immunity including the T- and B-cell driven immune responses. The phases and clinical faces of myocarditis are summarized. Up-to-date information on current treatment options starting with heart failure and antiarrhythmic therapy are provided. Although inflammation can resolve spontaneously, specific treatment directed to the causative aetiology is often required. For fulminant, acute and chronic autoreactive myocarditis immunosuppressive treatment is beneficial, while for viral cardiomyopathy and myocarditis ivIg can resolve inflammation and is as successful as interferon therapy in enteroviral and adenoviral myocarditis. For Parvo B19 and HHV6 myocarditis eradication of the virus is still a problem by any of these treatment options. Finally, the potential of stem cell therapy has to be tested in future trials. In virus-negative, autoreactive perimyocardial disease a locoregional approach with intrapericardial instillation of high local doses of triamcinolone acetate has been shown to be highly efficient and with few systemic side-effects.
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Standard and etiology-directed evidence-based therapies in myocarditis: state of the art and future perspectives. Heart Fail Rev 2012; 18:761-95. [DOI: 10.1007/s10741-012-9362-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Imaging assessment of cardiovascular disease in systemic lupus erythematosus. Clin Dev Immunol 2011; 2012:694143. [PMID: 22110536 PMCID: PMC3202117 DOI: 10.1155/2012/694143] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/26/2011] [Accepted: 08/26/2011] [Indexed: 11/17/2022]
Abstract
Systemic lupus erythematosus is a multisystem, autoimmune disease known to be one of the strongest risk factors for atherosclerosis. Patients with SLE have an excess cardiovascular risk compared with the general population, leading to increased cardiovascular morbidity and mortality. Although the precise explanation for this is yet to be established, it seems to be associated with the presence of an accelerated atherosclerotic process, arising from the combination of traditional and lupus-specific risk factors. Moreover, cardiovascular-disease associated mortality in patients with SLE has not improved over time. One of the main reasons for this is the poor performance of standard risk stratification tools on assessing the cardiovascular risk of patients with SLE. Therefore, establishing alternative ways to identify patients at increased risk efficiently is essential. With recent developments in several imaging techniques, the ultimate goal of cardiovascular assessment will shift from assessing symptomatic patients to diagnosing early cardiovascular disease in asymptomatic patients which will hopefully help us to prevent its progression. This review will focus on the current status of the imaging tools available to assess cardiac and vascular function in patients with SLE.
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Matucci-Cerinic M, Seferović PM. Heart involvement in autoimmune rheumatic diseases: the "phantom of the opera". Rheumatology (Oxford) 2007; 45 Suppl 4:iv1-3. [PMID: 16980716 DOI: 10.1093/rheumatology/kel316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M Matucci-Cerinic
- Department of Medicine and Surgery, Division of Medicine I and Rheumatology University of Florence, AOUC, Florence, Italy.
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