Death by aortoesophageal fistula due to disseminated tuberculosis: a case study

Tuberculosis remains a serious public health problem worldwide, especially in Korea. Although tuberculosis is generally considered a non-fatal chronic disease, deaths have occurred. In this case study, a 68-year-old man was admitted to the hospital with dyspepsia, vomiting, and abdominal pain. Nine hours later, he suffered severe hematemesis and died despite cardiopulmonary resuscitation. A medico-legal autopsy was performed and an external examination revealed no external injuries. However, an internal examination revealed an aortoesophageal fistula and a large amount of blood in the stomach. A histologic examination confirmed tuberculous mediastinitis with disseminated tuberculosis involving multiple organs, including the heart, lungs, liver, kidneys, and spleen. Both an aortoesophageal fistula and sudden death due to tuberculosis infection are rare. This paper reports the case of a fatal aortoesophageal fistula associated with disseminated tuberculosis.

Tubercular granuloma in the myocardium: an autopsy report

Granulomatous myocarditis is a rare disorder of the myocardium, and is usually associated with various inflammatory and autoimmune conditions. We report granulomatous myocarditis in an apparently healthy 58-year-old Indian man, who developed sudden chest pain and died while being escorted to the hospital. At the autopsy, no gross distinct cardiac lesions were observed. The histopathological sections from the left ventricular apex revealed a granuloma comprising a central area of caseous necrosis surrounded by lymphocytes, and epithelioid, plasma and Langhans giant cells. Myocardial tuberculosis was suspected as the underlying aetiology based on the histological features of the granuloma.

Bicaval obstruction complicating right atrial tuberculoma: the diagnostic value of cardiovascular MR

Cardiac tuberculosis is rare and usually involves the pericardium. Myocardial tuberculoma is a very rare occurrence and only a few cases were reported. We describe the use of cardiovascular magnetic resonance in the diagnosis of a rare case of cardiac tuberculoma involving the right atrium which was complicated by a bicaval obstruction. The patient made a remarkable improvement with the anti-tuberculous treatment. To our knowledge, this complication has never been reported in relation to cardiac tuberculoma.

Resolution of nodular myocardial tuberculosis demonstrated by contrast-enhanced magnetic resonance imaging

In sub-Saharan Africa, pericardial tuberculosis is frequently diagnosed in HIV sero-positive patients. Myocardial involvement has only rarely been reported. We present an HIV sero-positive patient in whom both pericardial and myocardial tuberculosis were diagnosed, and highlight the value of cardiac magnetic resonance imaging in the diagnosis and management of this condition.

Endovascular stent graft treatment of leaking thoracic aortic tuberculous pseudoaneurysm

Mycobacterium tuberculosis infection is one of the leading causes of death from communicable diseases worldwide. However, the incidence of leaking thoracic aortic tuberculous pseudoaneurysms is rare as a complication. Conventional treatment of a leaking tuberculous pseudoaneurysm involves surgery with graft interposition or patch repair. With the emergence of stent graft treatment as a viable option for leaking pseudoaneurysms, we report a 63-year-old man who had his leaking toracic aortic tuberculous pseudoaneurysm treated with endovascular stent grafting.

Tubercular pseudoaneurysms of aorta

BACKGROUND

Tubercular pseudoaneurysm of aorta is a rare but important complication of tuberculosis. With worldwide resurgence of tuberculosis due to increasing incidence of drug-resistant tuberculosis and its association with acquired immunodeficiency syndrome, the tubercular pseudoaneurysm has become a real clinical entity.

METHODS

In the past 3 years, 5 young patients (22 to 40 years) presented with tubercular pseudoaneurysm. Site of involvement included ascending aorta, distal aortic arch, proximal descending thoracic aorta, distal descending thoracic aorta, and infrarenal abdominal aorta. Two patients had macroscopic focus of tuberculosis in the nearby vicinity, and all 5 patients had evidence of active/treated pulmonary pericardial tuberculosis. All patients either had received antitubercular therapy previously or were receiving it at the time of presentation. Rapid deterioration in the clinical status was the most marked clinical feature. All patients underwent operation. Graft interposition was performed in 2, patch repair in 2, and direct closure of the rent was performed in 1 patient. All 5 patients received antitubercular therapy in the postoperative period.

RESULTS

All patients survived the operation and were discharged from the hospital. One patient developed recurrence at the original site after 8 months and died at reoperation. The remaining patients are symptom free at 18 to 36 months postoperatively.

CONCLUSIONS

A combination of chemotherapy and operation yields gratifying results for the treatment of tubercular pseudoaneurysm.

CT and MR findings in a calcified myocardial tuberculoma of the left ventricle

Tuberculosis can involve a multitude of organ tissues but generally affects the respiratory tract. Heart tuberculosis is rare, and the pericardium is the most common location reported in the literature, accounting for 0.5% of extrapulmonary tuberculosis. Isolated myocardial tuberculosis is a very unusual occurrence, with only a few case reports in the literature, usually diagnosed at necropsy. Findings of myocardial tuberculoma on cross-sectional images previously have not been reported. We present computed tomography and magnetic resonance imaging findings of an isolated calcified myocardial tuberculoma.

Sudden death caused by myocardial tuberculosis: case report and review of the literature

A 25-year-old fit man died suddenly while playing social soccer. Autopsy revealed an infiltrative lesion involving the left ventricle with overlying pericarditis. No other significant pathologic changes were observed. Histologic examination showed necrotizing granulomatous inflammation. No acid-fast bacilli were demonstrated in the pericardial fluid or on histologic examination. The presence of Mycobacterium tuberculosis DNA complex was confirmed by use of the ligase chain reaction technique. The differential diagnosis of myocardial tuberculosis includes sarcoidosis, rheumatic fever, rheumatoid arthritis, giant-cell-containing tumors, idiopathic (giant-cell) myocarditis, and bacterial infections such as tularemia and brucellosis. This case illustrates the protean manifestations of tuberculosis and highlights the use of molecular biologic techniques in arriving at a definitive diagnosis in cases of suspected tuberculosis.

Tuberculous aortitis with an aortoduodenal fistula presenting as recurrent gastrointestinal bleeding

Tuberculous aortitis with a tuberculous mycotic aneurysm and an aortoduodenal fistula was diagnosed in a 38-year-old man with tuberculous cervical lymphadentitis and a 3-month history of recurrent gastrointestinal bleeding, in whom extensive investigation of the digestive tract had not revealed a bleeding lesion. Either by septic embolism or by direct extension from a neighboring focus, tuberculous infection can cause a mycotic aortic aneurysm with subsequent fistulation to the duodenum.

Subacute tuberculous pericarditis with fibroelastic constriction diagnosed upon pericardiectomy

A patient with subacute pericarditis showed no evidence suggesting tuberculosis until pericardiectomy was performed because of hemodynamic deterioration. The excised pericardium had a rubbery fibroelastic consistency; histologically, there were granulomatous changes characteristic of tuberculosis. Although tuberculous pericarditis is a difficult diagnosis, this case illustrates the diagnostic and therapeutic importance of early pericardiectomy before myocardial inflammatory infiltration occurs together with end-stage pericardial fibrosis and calcification.

Papulonecrotic tuberculid. A clinical, histopathological, and immunohistochemical study of 15 patients

We report 10 women and five men with papulonecrotic tuberculid, an uncommon form of cutaneous tuberculosis (TB). The mean age was 22.6 years (range, 2 1/2-35 years) at presentation. The Mantoux test was strongly positive in 13 patients. Five patients showed presumptive evidence of associated TB; in one case, the presence of TB was proven by culture. Response to anti-TB was dramatic in all cases. Clinical findings were similar to those previously published. We emphasize the simultaneous occurrence of erythema induratum, associated Takayasu's disease, possible associated phlebitic tuberculid, and clinical mimicry of acute bacterial endocarditis. The main histopathological findings obtained from 27 biopsy specimens included dermal necrosis (26 of 27 cases), a poorly formed granulomatous infiltrate (27 of 27 cases), vasculitis (11 of 27 cases), perivascular spongy edema (11 of 27 cases), and follicular necrosis or suppuration (five of 27 cases). A Ziehl-Neelsen stain was negative in all biopsy specimens. Immunohistochemical labeling revealed a preponderance of T-lymphocytes (UCHL-1+), monocytes-macrophages (S-100+), and Langerhans cells (ACT+), indicative of a type IV hypersensitivity reaction. B-lymphocytes (L26+) were sparse. Conditions that may be confused with PNT on clinical or histopathological ground include pityriasis lichenoides et varioliformis acuta, papular urticaria, papulopustular syphilide, miliary TB, septicemia, perforating granuloma annulare, chondrodermatitis nodularis, reactive perforating collagenosis, allergic granulomatosis, suppurative folliculitis, and infectious causes of palisading granulomas. Papulonecrotic tuberculid has distinct clinical, histopathological, and immunohistochemical features. Awareness of this entity is important since an appropriate diagnosis is necessary for the institution of timely curative treatment.

Tuberculosis of the renal artery

A young female who underwent nephrectomy for renovascular hypertension was diagnosed on histology to have tuberculosis of the renal artery. This was an isolated finding as there was no tuberculous infection elsewhere including tissues in the vicinity of the vessels. A survey of literature did not yield any reports of tuberculous renal arteritis, making this the first such case.

Tuberculous myocarditis presenting as sudden cardiac death

A 71-year-old Chinese male presented as sudden death and autopsy revealed miliary tuberculosis with tuberculous myocarditis. Though miliary tuberculosis is not as common as in the past, it remains one of the possible causes of sudden cardiac death.

[Tuberculous myocarditis. Presentation of a case and review of the literature]

We report a case of a 22 year-old drug addict man with overt heart failure and cardiomegaly. The patient had no prior history of tuberculosis and not clinical features to suggest this diagnosis. Tuberculosis myocarditis was found at the necropsy. It is important to point out the frequency of this pathology, the uncommon clinical presentation of this case; as well as the lack of immunologic response to the tuberculous bacillus.

Tuberculous aneurysm of the descending thoracic aorta

Tuberculous aneurysm of the descending thoracic aorta is a rare entity. To our knowledge the present case is the sixth on record to have been successfully treated surgically. These aneurysms present the usual difficulties of surgical therapy of the thoracic aorta: spinal cord and renal circulatory protection and the choice between distant or in situ revascularization. This case is of particular interest for its evolution and its treatment: resection of the aneurysm without shunting and insertion of a graft in situ covered by a flap of omentum.

[Tuberculoma of the heart. Contribution of echography. Apropos of a case]

An 18-year old woman was admitted to hospital with signs of right heart failure and atrial tachycardia. Ultrasounds showed a tumoral mass in the tricuspid valve. Post-mortem examination revealed that the mass was a tuberculoma obstructing the tricuspid orifice. The exceptional character of this case is emphasized: lesions of the heart have been found in less than 0.3 p. 100 of tuberculous patients autopsied. The different anatomical aspects of tuberculosis of the heart are mentioned, and it is suggested that echocardiography should be performed systematically in all patients with severe, disseminated tuberculosis. Tuberculoma of the heart should figure on the list of intraparietal and intraluminal masses visualized at echocardiography.

Cardiac tuberculosis. A study of 19 patients

Myocardial tuberculosis (TB) was encountered in 19 patients (0.14%) at autopsy over a 27-year period. Eight patients had miliary lesions, and 11 had nodular lesions. Myocardial TB was diagnosed ante mortem in only one patient. Three patients developed left ventricular aneurysms. Tuberculous lesions were most commonly observed in the ventricles. Nodular tuberculous lesions produced no significant cardiac dysfunction, and the severe systemic symptoms of patients with miliary TB overshadowed the effects of cardiac miliary TB. Two additional patients with disseminated TB showed a focal lymphocytic myocarditis unassociated with diagnostic tuberculous lesions in the heart. This myocarditis differed histologically from the diffuse myocarditis described in the older literature.

Coronary vasculitis. A review in the current scheme of classification of vasculitis

Coronary artery disease is overwhelmingly atherosclerotic in nature, but inflammatory disease of the coronary arteries can be just as life-threatening a cause of ischemic heart disease in all age groups. Coronary vasculitis is not short in variety; as a clinicopathologic entity it spans the entire spectrum of systemic vasculitides. Coronary vasculitis is most closely associated with the polyarteritis group of necrotizing angiitis, vasculitis of collagen-vascular disease, and granulomatous giant cell arteritis. This article provides an overview of coronary vasculitis as an independent entity as well as a manifestation of systemic vasculitis, both the common and the uncommon varieties.

Tuberculous aortitis with associated necrosis and perforation: treatment and options

Tuberculous aortitis is a rare entity and its association with necrosis and perforation is even more unusual. Our pulmonary medicine service originally evaluated an elderly woman with a right pleural effusion and upper lobe infiltrate thought to be tuberculosis. An abdominal CT scan performed at that time showed extensive periaortic adenopathy. Isoniazid and rifampin were started, but both were stopped by the patient after less than 6 months of therapy. The patient later had night sweats, a left pleural effusion, and a tender abdominal mass thought to be a symptomatic aneurysm. At operation, the aorta was necrotic and had an inflammatory mass and perforation on the left side. Infrarenal aortic ligation and resection were performed to control infection. A previously placed axillofemoral graft obviated the need for concomitant revascularization. The patient was treated postoperatively with isoniazid and rifampin until hyperbilirubinemia developed, which necessitated alternate therapy with ethambutol and streptomycin. The patient died one month after operation of a presumed pulmonary embolus.

Cardiac tuberculosis: TB of the endocardium

Tuberculosis involving the endocardium is extremely rare. The diagnosis is usually made during autopsy. Often there is involvement of other parts of the heart as well as other regions of the body. The infection is a result of direct extension from the myocardium or hematogenous spread. Two cases of disseminated tuberculosis with endocardial involvement are reported. In Case 1 miliary tuberculosis was diagnosed during life but the patient succumbed to extensive disease on the third hospital day. The patient in Case 2 presented with congestive cardiac failure and the possibility of tuberculosis was not suspected during life.

Sudden death due to myocardial tuberculosis

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Isolated interventricular septal tuberculoma causing complete heart block

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Late generalized tuberculosis: a clinical pathologic analysis and comparison of 100 cases in the preantibiotic and antibiotic eras

1. The clinical and pathologic findings in 100 patients with late generalized tuberculosis (LGT) are described and a comparison made between the findings occurring in the preantibiotic era with those in the early antibiotic period. The clinical presentation of LGT as seen in a general hospital has changed. Whereas, in the preantibiotic era, LGT was often the primary disease, occurring principally in young adults and frequently associated with pulmonary symptoms, in the antibiotic era, LGT commonly occurred together with and was frequently obscured by other diseases, often afflicted the elderly and was much less frequently accompanied by pulmonary symptoms. Symptoms related to extrapulmonary organ tuberculosis in this era were absent in 30% of patients. 2. Diagnostic difficulties in LGT arose because 20% of patients exhibited no constitutional symptoms prior to hospitalization, a history of tuberculosis often was lacking, fever curves and hematologic findings, with the exception of a left shift, commonly were non-specific, monocytosis frequently was absent, chest x-rays were non-diagnostic in about 50% of the cases, and anergy occured particularly in the elderly. 3. Caseous foci responsible for hematogenous spread generally derived from reactivated old caseous lesions located principally in the lungs, lymph nodes, bone, central nervous system, adrenals, and genito-urinary tract. Simultaneous reactivation of anatomically unrelated foci in multiple organs and lymph nodes occurred in 54% of cases. Although chronic pulmonary tuberculosis commonly was associated with LGT in the preantibiotic era, this association was uncommon in recent times. Chronic pulmonary tuberculosis served as the sole source for hematogenous dissemination infrequently and the pulmonary lesions responsible were acute. 5. Large caseous foci located in lymph nodes, bone, prostate gland, and central nervous system frequently occurred in the absence of clinical symptoms and therefore were undiagnosable. 6. The clinical course of LGT was often rapid, although histologic features indicated that the course in some patients was protracted or even episodic. 7. Miliary tubercles very frequently showed caseation and often they enlarged to cause progressive or complicated lesions. Chest x-rays and culture diagnoses were dependent on the formation of these complicated lesions. 8. Liver biopsy is recommended as a diagnostic procedure since 97% of patients exhibited granulomata in this organ. Of diagnostic importance is the fact that 90% of these granulomata exhibited caseous necrosis. Twenty-two percent of patients with liver granulomatas did not show tubercles in the bone marrow. 9. Multiple pathways rather than an exlcusive lymphangitic route were available for tubercle bacilli to gain access to the blood stream and cause hematogenous dissemination.

Tuberculous endocarditis: A report of 2 cases

Two patients with tuberculous endocarditis are described. In one patient the condition developed on a mitral valve prosthesis and in the other in thrombus adherent to a ventriculo-atrial shunt.

Tuberculous pericarditis. A review of 100 cases

A retrospective survey of 100 Black patients with presumed tuberculous paricarditis showed that 82 presented with pericardial effusion while 18 had constrictive pericarditis. The mortality rate was 17%. Of the 82 patients with pericardial effusion, 15 developed 'constricting pericarditis' within 4 months; 12 required pericardiectomy. Sixteen patients died of cardiac tamponade; the effusion had been confirmed by a radio-isotope heart pool scan but had not been aspirated. This emphasizes the need for early and repeated pericardial aspiration. The fate of 38 rural patients with pericardial effusion was not known. Of the 18 patients with constrictive pericarditis, 7 underwent pericardiectomy, while 3 refused operation.

Rupture of a tuberculous pseudoaneurysm of the innominate artery into the trachea and esophagus: report of a case and review of the literature

Spontaneous rupture of a tuberculous pseudoaneurysm of the innominate artery, undiagnosed until necropsy, occurred simultaneously into the trachea and the esophagus in a patient receiving anti-tuberculosis chemotherapy. This is the first reported instance of a tuberculous innominate artery aneurysm, the third tuberculous aneurysm with rupture into the trachea, the sixth into the esophagus, and the first with rupture into both structures. A review of the literature relating to tuberculous aneurysms of the major arteries is provided.

[Coronary embolism in the medico-legal autopsy material (author's transl)]

The author discusses the problem of diagnosis and evaluation of coronary embolism (CL). He presents four cases of his own observation, including histological examinations and a review of the pertinent literature. The following facts are necessary to make the diagnosis of CE: 1. An embolus consisting of foreign elements like tumor-cells, suture material or similar things. 2. Dilatation of the arterial lumen where the embolus is found. 3. No adherence between the embolus and the arterial wall. 4. Normal consistence of the arterial wall. 5. Knowledge of the source of the embolus. 6. Histomorphological conformity of the source of the embolus and the embolus itself. The mechanisms of flow and the interrelation between trauma and CE which are often difficult to judge in forensic medicine are discussed.

[Complete atrio-ventricular block caused by tuberculoma of the inter-atrial septum. Histological analysis]

A syndrome of obstacle to the outflow of the left ventricle was found in a woman with atrio-ventricular block with narrow ventricular complexes. A tuberculoma of the intar-atrial septum was responsible both for the obstacle to left ventricular ejection and for the block which was found to be proximal on microscopic examination.

Case of post-primary tuberculosis and massive haematemesis

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