Patra et al., Int J Cardiovasc Res 2015, 4:1
http://dx.doi.org/10.4172/2324-8602.1000192
International Journal of
Cardiovascular Research
Case Report
A SCITECHNOL JOURNAL
Chronic Thromboembolic
Pulmonary Hypertension in a Case
with Multi-Drug Resistant
Pulmonary Tuberculosis
Soumya Patra*, Beeresh Puttegowda, Ravindranath KS and
Manjunath CN
Post doctoral trainee, Department of Cardiology, Sri Jayadeva Institute of
Cardiovascular Sciences and Research, Bangalore, Karnataka, India
*Corresponding author:Dr. Soumya Patra, Post doctoral trainee, department of
cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research,
Bangalore,
560069,
India,
Tel:
+919686480971;
E-mail:
[email protected]
Echocardiography revealed dilated right atrium & ventricle (Figure
1A) with moderate tricuspid regurgitation and pulmonary artery
systolic pressure was 64 mm of Hg. It also demonstrated a clot in the
left pulmonary artery (LPA) protruding into main pulmonary artery
(MPA) without any flow towards LPA (Figure 1B) with dilated MPA.
CT pulmonary angiogram (CTPA) revealed the calcified thrombus in
the LPA and there was diminished vascularity of left lung and
fibrocavitary lesion in the right lung (Figure 1C & D). She was on
treatment with injection of kanamycin with oral ethionamide,
cycloserine, pyrazinamide, levofloxacin and ethambutol for MDR-TB
as per sputum culture & sensitivity report. She was also given oral
diuretics, digoxin and warfarin for the treatment for right heart failure
and chronic pulmonary embolism.
Rec date: Aug 28, 2014 Acc date: Nov 28, 2014 Pub date: Jan 01, 2015
Abstract
Pulmonary tuberculosis is very common and multidrug
resistance (MDR) is emerging in the developing country. The
association with chronic pulmonary embolism is a rare entity.
We are reporting a case of 19-years old female with MDR
tuberculosis, had severe pulmonary hypertension and right
heart failure due to chronic pulmonary embolism.
Keywords: Pulmonary tuberculosis; Multidrug resistance; Chronic
pulmonary embolism
Introduction
Multidrug resistance (MDR) tuberculosis (TB) is creating a serious
threat to the society [1]. Pulmonary tuberculosis is rarely associated
with venous thromboembolism (VTE) or pulmonary embolism due to
its hypercoagulable states [2]. The reported rate of VTE in adult
patients with tuberculosis is about 3-10% [3] with only few reported
cases of acute pulmonary embolism [4,5]. We are reporting a case of
severe MDR pulmonary tuberculosis that also had chronic
thromboembolic pulmonary hypertension (CTEPH) as underlying
etiology for right heart failure. So far literature didn’t reveal any case of
CTEPH associated with pulmonary tuberculosis.
Case Report
A nineteen years old girl was referred to our hospital for evaluation
of congestive heart failure (CHF). She was a known case of multi drug
resistant (MDR) tuberculosis (TB). She had received anti-tubercular
therapy with both category I & II for 18 months. As she had sputum
positivity for tubercular bacilli even after treatment, she was put on
treatment for MDR-TB. Her weight was 30 kg and she had clubbing,
engorged neck vein, pedal edema and oxygen saturation in room air
was 85%. Blood investigation revealed presence of anaemia (Hb-10.2
gram/ dL), leucocytosis (total leucocyte count-12500/ cmm), and
normal liver & renal function test. She didn’t have seropositivity for
human immunodeficiency virus (HIV). Electrocardiogram showed tall
peak ‘P’ wave with features of right ventricular hypertrophy. Chest xray showed fibro-cavitary lesion in the right lower lobe.
Figure1: A & B- Echocardiography revealed dilated right atrium &
ventricle and present of clot in LPA protruding into MPA with
dilated pulmonary artery and there was no flow towards LPA, C &
D- CTPA images revealed calcified thrombus in the LPA and there
was diminished vascularity of left lung and fibrocavitary lesion in
the right lung.
Discussion
Nearly 50% of the world’s burden of MDR-TB cases is seen in India
and China and the situation of TB is further threatened by the
devastating effect of HIV [1]. Pulmonary tuberculosis is infrequently
complicated by venous thromboembolism (VTE), because of the
association between inflammation and haemostatic changes that can
result in a hypercoagulable state 2 The factors commonly associated
with the pathogenesis of VTE in TB are like alteration in the wall of
the vein, alteration in the blood constituents and slowing of the blood
stream 2 Different studies described that elevated plasma fibrinogen
level, with impaired fibrinolysis coupled with a decrease in thrombin
III, protein C and increased platelet aggregation appear to induce a
hypercoagulable state to favor the development of VTE in pulmonary
tuberculosis [2]. One study reported that VTE occurs in 1 out of every
140 patients with acute tuberculosis and it seems to develop mainly in
the first month of treatment, especially in those with a prolonged
hospital stay [3] pulmonary embolism (PE) is an infrequent
All articles published in International Journal of Cardiovascular Research are the property of SciTechnol and is protected
by copyright laws. Copyright © 2015, SciTechnol, All Rights Reserved.
Citation:
Patra S, Puttegowda B, Ravindranath KS, Manjunath CN (2015) Chronic Thromboembolic Pulmonary Hypertension in a Case with Multi-Drug
Resistant Pulmonary Tuberculosis. Int J Cardiovasc Res 4:1.
doi:http://dx.doi.org/10.4172/2324-8602.1000192
association of severe TB with only few reports is in the literature [2-5].
Another study reported that even in cases of pulmonary tuberculosis
without dyspnea, D-dimer seems to be useful for the early diagnosis of
pulmonary thromboembolism [4]. We are reporting a case who was
suffering from severe form of MDR-TB and later she developed
features of right heart failure. Corpulmonale could be due to either
hypoxia induced pulmonary hypertension or chronic thromboembolic
pulmonary hypertension (CTEPH). PE is particularly worrisome, and
its sequelae can lead to sudden death or CHF in young patients. 4 Both
conditions in our case aggravate pulmonary hypertension and results
in CHF. Though, favorable outcome of VTE in case pulmonary TB
was reported in the literature3 but it was not the scenario in our case.
We are highlighting an infrequent complication of TB so that high
suspicion, adequate prophylaxis, early diagnosis and management of
PE can play a vital role in the survival and prevention of CTEPH in
this subset of patients. Further study needs to conclude when to
suspect clinically and what should be the ideal screening test for PE in
a patient who also has severe pulmonary tuberculosis.
Volume 4 • Issue 1 • 1000192
References
1.
2.
3.
4.
5.
Sethi S, Mewara A, Dhatwalia SK (2013) Prevalence of multidrug
resistance in Mycobacterium tuberculosis isolates from HIV
seropositive and seronegative patients with pulmonary
tuberculosis in north India. BMC Infect Dis 13: 137.
El Fekih L, Oueslati I, Hassene H, Fenniche S, Belhabib D, et al.
(2009) Association deep veinous thrombosis with pulmonary
tuberculosis. Tunis Med 87: 328-329.
Shitrit D, Fox L, Preiss R, Raz M, Mtvitzuk A (2012) [Incidence
of venous thromboembolism in 700 patients with acute
tuberculosis]. Harefuah 151: 208-210, 254.
Komazaki Y, Sakakibara Y, Sakashita H, Miyazaki Y, Inase N
(2011) [Pulmonary thromboembolism with pulmonary
tuberculosis]. Kekkaku 86: 717-722.
Mohan B, Kashyap A, Whig J, Mahajan V (2011) Pulmonary
embolism in cases of pulmonary tuberculosis: a unique entity.
Indian J Tuberc 58: 84-87.
• Page 2 of 2 •