Tuberculosis and the Heart

Abstract

Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.

Keywords: heart; myocarditis; pericarditis; tuberculosis; vessels.

Figure 1. Estimated rates tuberculosis incidence per 100 000 population per year in 2018.

Modified from the World Health Organization Global Tuberculosis Report 2019 ¹ under the terms of the Attribution‐NonCommercial‐ShareAlike 3.0 IGO (CC BY‐NC‐SA 3.0 IGO) license. TB indicates tuberculosis.

Figure 2. A case of a patient with HIV presenting with constrictive pericarditis.

A 35‐year‐old man with HIV infection was diagnosed with disseminated Mycobacterium tuberculosis infection from bronchial, pericardial fluid, and pericardium samples (red arrowhead in A). Two months later, he presented with right‐sided heart failure. Echocardiography was compatible with constrictive pericarditis as shown by pericardial thickening (red arrowheads in B), and reduction of left ventricular inflow (E wave) >25% with inspiration (red arrow in C). Computed tomography of the chest also showed thickened pericardium and mild pericardial effusion (red arrows and red star, respectively, in D). Courtesy of Dr. Andres F. Miranda‐Arboleda, Department of Cardiology, Clínica CardioVID, Hospital Pablo Tobón Uribe, Universidad de Antioquia, Colombia. Modified from Miranda‐Arboleda et al ²⁷ .

Figure 3. Algorithm to guide diagnosis of cardiovascular tuberculosis.

ADA indicates adenosine deaminase; cMRI, cardiac magnetic resonance; CT, computed tomography; CXR, chest radiographs; ECG, electrocardiogram; INF‐γ, gamma interferon; PCR, polymerase chain reaction; PET/CT, positron emission tomography/computed tomography; and TB, tuberculosis.