Cardiac dysfunction in active pulmonary tuberculosis: Mysterious facts of TB’s pandora
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MIMSR Medical College, Latur, INDIA
Venkatesh Chest Hospital and Critical Care Center, Latur, INDIA
NIMS Medical College, Jaipur, Rajasthan, INDIA
Online publication date: 2023-01-14
Publication date: 2023-03-01
Electron J Gen Med 2023;20(2):em452
Cardiac dysfunction in pulmonary tuberculosis is relatively more common and underestimated due to lack of suspicion. We have studied prevalence of cardiac dysfunction in pulmonary tuberculosis with special emphasis on echocardiography, serum cortisol and its correlation in cases with unstable cardiorespiratory parameters.

Prospective, observational, complete workup, and one year follow up study conducted during January 2016 to December 2020 included 800 cases of active pulmonary tuberculosis with specified inclusion criteria of disproportionate tachycardia, tachypnea with or without hypoxia and shock. Cases with known risk factor for cardiac disease and taking cardiac medicines, and cases with pericardial effusion were excluded from study. All study cases were undergone protocolized analysis such as chest radiograph, pulse oximetry, ECG, sputum examination, cardiac enzymes (CPK-MB, NT-Pro-BNP, and cardiac troponins), serum cortisol, and echocardiography at entry point, at two and six months of treatment with anti-tuberculosis medicines as per NTEP. Statistical analysis was carried out by Chi-square test.

Observations and analysis:
In a study of 800 pulmonary tuberculosis cases, 56.00% (448/800) cases were males, and 44.00% (352/800) cases were females. Cases with BMI<18 was 41.62% (333/800) and BMI>18 was 58.37% (467/800). Radiological patterns as unilateral disease in 33.62% (269/800) & bilateral disease in 66.37% (531/800). Hemoglobin less than 10 gm% were documented in 85.12% (681/800) and above 10 gm% were in 14.87% (119/800) cases. Serum albumin less than 3.5 gm% and more than 3.5 gm% were observed in 48.12% (385/800) and 51.12% (415/800) cases respectively. Hypoxia was documented 26.12% (209/800) cases and normal oxygen saturation in 73.87% (591/800) cases. cases with normal and abnormal serum cortisol were 61.37% (491/800) & 38.62% (309/800) respectively. Sputum examination for AFB observed in 30.00% (240/800) and gene Xpert MTB/RIF documented in 51.37% (411/800) cases respectively. Bronchoscopy guided techniques were used in 149 cases and BAL smear AFB in 44.96% (67/149) cases, gene Xpert MTB/RIF in 97.31% (145/149) cases and MGIT culture in four cases (positive in 100% cases subjected to MGIT culture). We have observed global hypokinesia is predominant cardiac dysfunction documented in 82.21% (171/208) cases, followed by left heart systolic dysfunction in 16.34% (34/208) cases and left heart diastolic dysfunction in 75% (156/208) cases. Right heart dysfunction as dilated right atrium and right ventricle documented in 52.88% (110/208) cases and pulmonary hypertension in 40.38% (84/208) cases. Covariates such as age, gender, hemoglobin, BMI, serum cortisol, serum albumin, oxygen saturation and radiological involvement has significant association with cardiac dysfunction. (p<0.00001) Response to treatment with antituberculosis medicines and steroids has documented as improved in 77.40% cases (161/208) cases, persistent in 13.46% (28/2028) cases and progressive in 9.13% (19/208) cases. Final outcome of cardiac dysfunction in Pulmonary tuberculosis cases has significant association with serum cortisol level (p<0.00086).

Cardiac dysfunction is active pulmonary tuberculosis needs prompt workup in presence of disproportionate tachypnea, tachycardia with or without hypoxia and shock. Echocardiography is basic tool to evaluate these cases and global hypokinesis is most common abnormality. Serum cortisol abnormality documented in fair number of cases and very well correlated with left ventricular dysfunction abnormalities. Steroids with antituberculosis treatment backup is mainstay protocol during management of these cases. Cardiac dysfunction is reversible in majority of cases and proportionate number shown complete improvement in cardiac dysfunction.

WHO. Global tuberculosis report 2019. World Health Organization; 2020. Available at: https://www.who.int/tb/publica... (Accessed: 10 March 2020).
WHO. Global tuberculosis control: Surveillance, planning, financing. World Health Organization; 2009. Available at: https://apps.who.int/iris/hand... (Accessed: 10 March 2020).
Bawri S, Ali S, Phukan C, Tayal B, Baruwa P. A study of sputum conversion in new smear positive pulmonary tuberculosis cases at the monthly intervals of 1, 2 & 3 month under directly observed treatment, short course (dots) regimen. Lung India. 2008;25(3):118-23. https://doi.org/10.4103/0970-2... PMid:20165663 PMCid:PMC2822329.
Adewole OO, Erhabor GE, Ogunrombi AB, Awopeju FA. Prevalence and patient characteristics associated with pleural tuberculosis in Nigeria. J Infect Dev Ctries. 2010;4(4):213-7. https://doi.org/10.3855/jidc.6... PMid:20440058.
Anders JM. Tuberculosis of the myocardium. JAMA. 1902;39(18):1081-6. https://doi.org/10.1001/jama.1....
Mayosi BM. Contemporary trends in the epidemiology and management of cardiomyopathy and pericarditis in sub‐Saharan Africa. Heart. 2007;93(10):1176-83. https://doi.org/10.1136/hrt.20... PMid:17890693 PMCid:PMC2000928.
Burgos LM, Farina J, Liendro MC, et al. Neglected tropical diseases and other infectious diseases affecting the heart. The NET‐heart project: Rationale and design. Glob Heart. 2020;15(1):60. https://doi.org/10.5334/gh.867 PMid:32923353 PMCid:PMC7473196.
Ortiz HIA, Farina JM, Saldarriaga C, et al. Human African trypanosomiasis & heart. Expert Rev Cardiovasc Ther. 2020;18(12):859-65. https://doi.org/10.1080/147790... PMid:32967478.
Guttman PH. Addison’s disease–A statistical analysis of 566 cases and a study of pathology. Arch Pathol. 1930;10:742-5.
Cushner GB, Zahler SF, Hills AG. Untreated Addison’s disease complicated by pulmonary congestion due to left ventricular failure. Ann Intern Med. 1963;58:341-6. https://doi.org/10.7326/0003-4... PMid:14024378.
Afzal A, Khaja F. Reversible cardiomyopathy associated with Addison’s disease. Can J Cardiol. 2000;16(3):377-9.
Wolff B, Machill K, Schulzki I, Schumacher D, Werner D. Acute reversible cardiomyopathy with cardiogenic shock in a patient with Addisonian crisis: A case report. Int J Cardiol. 2007;116(2):e71-3. https://doi.org/10.1016/j.ijca... PMid:17079038.
Krishnamoorthy A, Mentz RJ, Hyland KA, et al. A crisis of the heart: An acute reversible cardiomyopathy bridged to recovery in a patient with addison’s disease. ASAIO J. 2013;59(6):668-70. https://doi.org/10.1097/MAT.00... PMid:24172274.
Goodof II, Macbryde CM. Heart failure in Addison’s disease with myocardial changes of potassium deficiency. J Clin Endocrinol Metab. 2008;4(1):30-4. https://doi.org/10.1210/jcem-4....
Rose AG. Cardiac tuberculosis. A study of 19 patients. Arch Pathol Lab Med. 1987;111(5):422-6.
Liu A, Hu Y, Coates A. Sudden cardiac death and tuberculosis–how much do we know? Tuberculosis (Edinb). 2012;92(4):307-13. https://doi.org/10.1016/j.tube... PMid:22405969.
Yilmaz A, Kindermann I, Kindermann M, et al. Comparative evaluation of left and right ventricular endomyocardial biopsy: Differences in complication rate and diagnostic performance. Circulation. 2010;122(9):900-9. https://doi.org/10.1161/CIRCUL... PMid:20713901.
Kalam K, Otahal P, Marwick TH. Prognostic implications of global LV dysfunction: A systematic review and meta-analysis of global longitudinal strain and ejection fraction. Heart. 2014;100(21):1673-80. https://doi.org/10.1136/heartj... PMid:24860005.
Imazio M, Brucato A, Barbieri A, et al. Good prognosis for pericarditis with and without myocardial involvement: Results from a multicenter, prospective cohort study. Circulation. 2013;128(1):42-9. https://doi.org/10.1161/CIRCUL... PMid:23709669.
Syed FF, Aje A, Ntsekhe M, et al. Resolution of nodular myocardial tuberculosis demonstrated by contrast-enhanced magnetic resonance imaging. Cardiovasc J Afr. 2008;19(4):198-9.
Jeilan M, Schmitt M, McCann G, Davies J, Leverment J, Chin D. Cardiac tuberculoma. Circulation. 2008;117(7):984-6. https://doi.org/10.1161/CIRCUL... PMid:18285579.
Immer FF, Pirovino M, Saner H. [Isolated tuberculosis of the heart: A clinical and echocardiography follow-up]. Z Kardiol. 1997;86(1):15-9. https://doi.org/10.1007/s00392... PMid:9133119.
Breton G, Leclerc S, Longuet P, Leport C, Vildé J-L, Laissy J-P. [Myocardial localisation of tuberculosis: The diagnostic value of cardiac MRI]. Presse Med. 2005;34(4):293-6. https://doi.org/10.1016/S0755-... PMid:15798549.
Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: Feasibility and potential clinical usefulness. J Am Coll Cardiol. 1997;29(6):1317-23. https://doi.org/10.1016/S0735-... PMid:9137230.
Biesbroek PS, Beek AM, Germans T, Niessen HWM, van Rossum AC. Diagnosis of myocarditis: Current state and future perspectives. Int J Cardiol. 2015;191:211-9. https://doi.org/10.1016/j.ijca... PMid:25974197.
Wallis PJ, Branfoot AC, Emerson PA. Sudden death due to myocardial tuberculosis. Thorax. 1984;39(2):155-6. https://doi.org/10.1136/thx.39... PMid:6701827 PMCid:PMC459744.
Amonkar G, Rupani A, Shah V, Parmar H. Sudden death in tuberculous myocarditis. Cardiovasc Pathol. 2009;18(4):247-8. https://doi.org/10.1016/j.carp... PMid:18402837.
Chapman RC, Claydon SM. Mycobacterium tuberculosis: A continuing cause of sudden and unexpected death in west London. J Clin Pathol. 1992;45(8):713-5. https://doi.org/10.1136/jcp.45... PMid:1401185 PMCid:PMC495152.
Shapiro M, Zalewski S, Steiner Z, et al. Adrenal insufficiency in a general hospital over a 14-year period. Isr J Med Sci. 1984;20(5):381-7.
Vita JA, Silverberg SJ, Goland RS, Austin JH, Knowlton AI. Clinical clues to the cause of Addison’s disease. Am J Med. 1985;78(3):461-6. https://doi.org/10.1016/0002-9... PMid:3976705.
Nerup J. Addison’s disease-clinical studies. A report of 108 cases. Acta Endocrinol (Copenh). 1974;76(1):127-41. https://doi.org/10.1530/acta.0... PMid:4406578.
Lack EE, Kozakewich HPW. Embryology, developmental anatomy, and selected aspects of nonneoplastic pathology. In: Lack EE, editor. Contemporary issues in surgical pathology. New York, NY: Churchill Livingstone; 1990.
Alvarez S, McCabe WR. Extrapulmonary tuberculosis revisited: A review of experience at Boston City and other hospitals. Medicine (Baltimore). 1984;63(1):25-55. https://doi.org/10.1097/000057... PMid:6419006.
Kannan, CR. The adrenal gland. New York, NY: Plenum Medical Book Company; 1988. https://doi.org/10.1007/978-1-... PMCid:PMC281838.
Watanabe E, Ogawa K, Ban M, Satake T. Sympathetic nervous systems in chronic hypoxic states from pulmonary tuberculosis: A clinical study on plasma norepinephrine and cyclic AMP levels. Jpn J Med. 1981;20(3):180-7. https://doi.org/10.2169/intern... PMid:6279943.
Baciewicz AM, Self TH, Bekemeyer WB. Update on rifampin drug interactions. Arch Intern Med. 1987;147(3):565-8. https://doi.org/10.1001/archin... PMid:2881523.
Prasad GA, Sharma SK, Mohan A, et al. Adrenocortical reserve and morphology in tuberculosis. Indian J Chest Dis Allied Sci. 2000;42(2):83-93.
Sharma SK, Tandan SM, Saha PK, Gupta N, Kochupillai N, Misra NK. Reversal of subclinical adrenal insufficiency through antituberculosis treatment in TB patients: A longitudinal follow up. Indian J Med Res. 2005;122(2):127- 31.
Zargar AH, Sofi FA, Akhtar MA, Salahuddin M, Masoodi SR, Laway BA. Adrenocortical reserve in patients with active tuberculosis. J Pak Med Assoc. 2001;51(12):427-33.
Chan CH, Arnold M, Mak TW, Chan RC, Hoheisel GB, Chow CC. Adrenocortical function and involvement in high risk cases of pulmonary tuberculosis. Tuber Lung Dis. 1993;74(6):395-8. https://doi.org/10.1016/0962-8... PMid:8136493.
Ellis ME, Tayoub F. Adrenal function in tuberculosis. Br J Dis Chest. 1986;80(1):7-12. https://doi.org/10.1016/0007-0... PMid:3004550.
Mugusi F, Swai AB, Turner SJ. Hypoadrenalism in patients with pulmonary tuberculosis in Tanzania: An undiagnosed complication. Trans soc Trop Med Hyg. 1990;84(6):849-51. https://doi.org/10.1016/0035-9... PMid:2096522.
Behera D, Dash RJ. Adreno-cortical reserve in pulmonary tuberculosis. J Assoc Physicians India. 1992;40(8):520-1.
Lavi A, Lipnitzky V, Feigl. [Adrenal insufficiency due to active tuberculosis]. Harefuah. 1984;107(3-4):64-5.
York EL, Enarson DA, Nobert EJ, Fanning FA, Sproule BJ. Adrenocortical function in patients investigated for active tuberculosis. Chest. 1992;101(5):1338-41. https://doi.org/10.1378/chest.... PMid:1582294.
Caforio ALP, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34(33):2636-48. https://doi.org/10.1093/eurhea... PMid:23824828.
Rodriguez-Takeuchi SY, Renjifo ME, Medina FJ. Extrapulmonary tuberculosis: Pathophysiology and imaging findings. Radiographics. 2019;39(7):2023-37. https://doi.org/10.1148/rg.201... PMid:31697616.
Ohene SA, Bakker MI, Ojo J, Toonstra A, Awudi D, Klatser P. Extra-pulmonary tuberculosis: A retrospective study of patients in Accra, Ghana. PLoS One. 2019;14(1):e0209650. https://doi.org/10.1371/journa... PMid:30625188 PMCid:PMC6326428.
Patil SV, Toshniwal S, Gondhali G, Patil D. Pulmonary tuberculosis with cardiac dysfunction: An ignored combination! Electron J Gen Med. 2023;20(1):em437. https://doi.org/10.29333/ejgm/....
Michira BN, Alkizim FO, Matheka DM. Patterns and clinical manifestations of tuberculous myocarditis: A systematic review of cases. Pan Afr Med J. 2015;21:118. https://doi.org/10.11604/pamj.... PMid:26327955 PMCid:PMC4546727.
Cowley A, Dobson L, Kurian J, Saunderson C. Acute myocarditis secondary to cardiac tuberculosis: A case report. Echo Res Pract. 2017;4(3):K25-9. https://doi.org/10.1530/ERP-17... PMid:28814447 PMCid:PMC5592778.
Vennamaneni V, Chohan F, Rad P, Rodriguez J, Gupta R, Michel G. Clinical presentation of a patient with tuberculous myocarditis: Case report and review of literature. Cureus. 2022;14(2):e22715. https://doi.org/10.7759/cureus... PMid:35371652 PMCid:PMC8971110.
Choudhary N, Abera H, Naik RB. Tuberculosis presenting with acute myocarditis and systolic heart failure. Cureus. 2021;13(2):e13229. https://doi.org/10.7759/cureus....
Huaman MA, Henson D, Ticona E, Sterling TR, Garvy BA. Tuberculosis and cardiovascular disease: Linking the epidemics. Trop Dis Travel Med Vaccines. 2015;1:10. https://doi.org/10.1186/s40794... PMid:26835156 PMCid:PMC4729377.
Shen C-H, Chou C-H, Liu F-C, et al. Association between tuberculosis and parkinson disease: A nationwide, population-based cohort study. Medicine (Baltimore). 2016;95(8):e2883. https://doi.org/10.1097/MD.000... PMid:26937925 PMCid:PMC4779022.
Sheu JJ, Chiou HY, Kang JH, Chen YH, Lin HC. Tuberculosis and the risk of ischemic stroke: A 3-year follow-up study. Stroke. 2010.;41(2):244-9. https://doi.org/10.1161/STROKE... PMid:20035070.
Musher DM, Abers MS, Corrales-Medina VF. Acute infection and myocardial infarction. N Engl J Med. 2019;380(2):171-6. https://doi.org/10.1056/NEJMra... PMid:30625066.
Huaman MA, Ticona E, Miranda G, et al. The relationship between latent tuberculosis infection and acute myocardial infarction. Clin Infect Dis. 2018;66(6):886-92. https://doi.org/10.1093/cid/ci... PMid:29069328 PMCid:PMC5850031.
Oh DK, Jo K-W, Kim Y-J, et al. Risk of cardiovascular event and influence of pyrazinamide in patients with active TB in South Korea: A population-based cohort study. Chest. 2017;152:A199.https://doi.org/10.1016/j.ches....
Seegert AB, Rudolf F, Wejse C, Neupane D. Tuberculosis and hypertension–a systematic review of the literature. Int J Infect Dis. 2017;56:54-61. https://doi.org/10.1016/j.ijid... PMid:28027993.
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