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Cardiovascular Disease |

Tuberculous Myopericarditis: A Rare Presentation in an Immunocompetent Host

Nayan Desai*, MD; Ankur Kalra, MD; Nidhi Jain, MD; Anjali Jain, MD
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Cooper University Hospital, UMDNJ, Camden, NJ


Chest. 2012;142(4_MeetingAbstracts):106A. doi:10.1378/chest.1390649
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Abstract

SESSION TYPE: Cardiovascular Student/Resident Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Tuberculosis is a common cause of pericardial disease in India. Myocardial involvement, although well described in the literature, is a rare manifestation of tuberculosis. We report a patient with disseminated tuberculosis with involvement of the myopericardium manifesting as cardiogenic shock.

CASE PRESENTATION: A 28-year-old male presented with 20 days history of low-grade fever, abdominal discomfort, exertional dyspnea, orthopnea, decreased urine output, facial puffiness, and pedal edema. Past medical history was non-contributory. Physical examination revealed a tachycardic, hypotensive male with elevated jugulovenous pressure at 14 cm of water, S3 gallop, bibasilar crackles, and pedal edema. Chest radiography showed cardiomegaly. Electrocardiogram revealed sinus tachycardia, incomplete right bundle branch block, and diffuse ST elevation in all leads. Cardiac troponins were positive. Urgent cardiac catheterization showed non-obstructive coronary disease. A 2-D echocardiogram revealed severe global hypokinesia, and left ventricular systolic dysfunction (35%). The patient was initiated on therapy with inotropic support. Cardiac magnetic resonance imaging showed evidence of non-infiltrative cardiomyopathy. Computed tomography of the chest and abdomen revealed enlarged mediastinal, mesenteric, and ileocecal lymph nodes suggestive of disseminated tuberculosis. A diagnosis of disseminated tuberculosis was made with involvement of the myocardium manifesting as cardiogenic shock. Four-drug antituberculous therapy (ATT) was initiated with adjunctive glucocorticoids. Follow-up at 2 months showed complete resolution of ST changes, with T-wave inversions, and normal left ventricular systolic function on 2-D echocardiogram. Repeat CT of the chest revealed pericardial calcification with regression in the size of lymph nodes.

DISCUSSION: Cardiac tuberculosis is a rare but well-recognized condition that was first reported many decades ago.[1] This condition most commonly affects the pericardium, while endocardial, myocardial, valvular or coronary arterial involvement is exceedingly rare. Increasing recognition of the entity and the use of endomyocardial biopsy may help in detecting more cases of such “curable” form of cardiomyopathy. The case presented in this report is a typical example of myopericardial involvement in tuberculosis.

CONCLUSIONS: Tuberculous myopericarditis is a known manifestation of tuberculosis. A high index of suspicion of myocardial involvement is necessary in patients with disseminated tuberculosis presenting with cardiogenic shock. Adjunctive therapy is indicated with corticosteroids for myocardial involvement, in addition to traditional four-drug ATT.

1) Horn H, Saphir O. The involvement of myocardium in tuberculosis: a review of literature and a report of three cases. Am Rev Tuberc.1935, 32:492-506.

DISCLOSURE: The following authors have nothing to disclose: Nayan Desai, Ankur Kalra, Nidhi Jain, Anjali Jain

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Cooper University Hospital, UMDNJ, Camden, NJ

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