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PULMONARY TUBERCULOSIS; Liaquat University Hospital Hyderabad / Jamshoro PULMONARY TUBERCULOSIS The Professional Medical Journal www.theprofesional.com ORIGINAL PROF-2730 1. Dip. Card, MD (Cardiology) Consultant Cardiologist PULMONARY TUBERCULOSIS; Liaquat University Hospital Hyderabad / Jamshoro. CARDIAC MANIFESTATIONS 2. FCPS Associate Professor Department of Cardiology Liaquat University of Medical and Dr. Mashooq Ali Dasti1, Dr. Syed Fasih Ahmed Hashmi2, Dr. Muhammad Sajid Abbas Jaffri3, Health Sciences Dr. Syed Ali Raza4, Dr. Shoaib Zahoor Junejo5, Dr. Saeem Akhtar6, Dr. Syed Zulfiquar Ali Shah7 (LUMHS), Jamshoro, Pakistan. 3. FCPS ABSTRACT… Objective: To determine the cardiac manifestations in patients with pulmonary Associate Professor Department of Medicine tuberculosis. Study Design: Case series study. Period: Jan 2014 to June 2014. Setting: Bahria University Medical & Dental Liaquat University Hospital Hyderabad. Methods: All the patients presented with shortness of College Karachi. breath, cough with sputum, fever, haemoptysis, anorexia and weight loss were recruited and 4. Department of Medicine then the subjects with early morning sputum positive for acid fast bacilli and radiological lesions Liaquat University Hospital Hyderabad, suggestive of pulmonary tuberculosis, of ≥20 years of age and either gender were enrolled and Sindh, Pakistan. entered in the study. The data was analyzed in SPSS 16 and the frequency and percentage was 5. Department of Medicine calculated. Results: Total one hundred patients with pulmonary tuberculosis were evaluated Liaquat University Hospital Hyderabad, for cardiac manifestation during six months study period. The mean ±SD for age of patients Sindh, Pakistan. with pulmonary tuberculosis was 45.21±8.95. The mean age ±SD of patient with cardiac 6. Department of Medicine manifestations was 48.95±5.53. The majority of the subjects were in 30-49 years age group Liaquat University Hospital with male predominance (p<0.01). The electrocardiographic findings were observed in 72/100 Hyderabad, Sindh, Pakistan. (72%) patients whereas echocardiographic changes were observed in 50/72 (69.4%) patients 7. Department of Medicine with pulmonary tuberculosis. The common ECG findings identified were tachycardia 30.5%, Liaquat University Hospital P-pulmonale 12.5% and PR prolonged in 9.7% patients with tuberculosis whereas the common Hyderabad, Sindh, Pakistan. echocardiographic findings noticed were pericardial effusion 42% and multiple abnormalities in 24% subjects with tuberculosis. Conclusions: The sinus tachycardia, cor-pulmonale and Correspondence Address: low voltage QRS complexes were predominant abnormalities on electrocardiograph whereas Dr. Syed Zulfiquar Ali Shah pericardial effusion was the common abnormality on echocardiography in patients with House No: 279, Doctor’s Colony Hirabad, Hyderabad, Sindh, Pakistan pulmonary tuberculosis. [email protected] Key words: Tuberculosis, electrocardiography and echocardiography. Article received on: 08/12/2014 Accepted for publication: Article Citation: Dasti MA, Hashmi SFA, Jaffri MSA, Raza SA, Junejo SZ, Akhtar S, Shah 21/01/2015 SZA. Cardiac manifestations of pulmonary tuberculosis. Professional Med J Received after proof reading: 02/06/2015 2015;22(6):733-737. INTRODUCTION events following engulfment.6 Tuberculosis remains a major health issue worldwide and infects one percent of the world’s Cardiovascular involvement occurs in one to two population each year.1 It is still most widespread percent of the patients with pulmonary tuberculosis disease despite advance methods of effective and usually affects the pericardium7, but very control and is one of the commonest infectious rarely myocardium and valves are involved.8,9 diseases presented in clinical practice.2 The lung Very less work had been done to determine the (pulmonary) is the commonest site of tuberculosis cardiac manifestations in pulmonary tuberculosis. infection in post natal life and is contaminated This study is done insight of increasing incidence diseases transmitted by aerosol.3 The interaction of pulmonary tuberculosis cases particularly of M. Tuberculosis with the human being in a developing country like Pakistan, as early initiates when droplets containing pathogens evaluation and proper treatment can prevent from infectious inhaled particles.4 The inhaled the patients to acquire various complications bacilli reach the alveoli and activated alveolar associated with tuberculosis. macrophages engulf the bacilli.5 The balance between defensive property of macrophage and PATIENTS AND METHODS the quantity and virulence of bacilli evaluates the This case series study was conducted at Liaquat Professional Med J 2015;22(6):733-737. www.theprofesional.com 733 PULMONARY TUBERCULOSIS 2 University Hospital Hyderabad. All the patients sweats 70%. Regarding radiographic evaluation presented with shortness of breath, cough the cavitating lesion were predominant in upper with sputum, fever, haemoptysis, anorexia and zones in contrast to mid and lower zones while weight loss were recruited and then the subjects regarding the demographic distribution majority with early morning sputum positive for acid fast of the patients belonged to rural areas of the bacilli and radiological lesions suggestive of province. The electrocardiographic findings were pulmonary tuberculosis, of ≥20 years of age observed in 72/100 (72%) patients whereas and either gender were enrolled and entered in echocardiographic changes were observed the study while the patients with sputum negative in 50/72 (69.4%) patients with pulmonary for pulmonary tuberculosis, pre-existing heart tuberculosis. diseases, hypertension, diabetes mellitus, COPD, bronchiectasis, pulmonary hypertension and GENDER Total corpulmonale due to other causes were considered Male Female in the exclusion criteria. The detail history, clinical AGE 13-19 3 2 5 examination was done and specific investigation 4.5% 6.1% 5.0% i.e. electrocardiography was advised and the 20-29 7 4 11 subjects with abnormal findings on ECG were 10.4% 12.1% 11.0% further evaluated by echocardiography to detect 30-39 20 3 23 the exact abnormality / cardiac complication due to 29.9% 9.1% 23.0% pulmonary tuberculosis. The written consent was 40-49 21 7 28 taken from every relevant patient for participation 31.3% 21.2% 28.0% in the study and the data was collected on pre- 50-59 4 12 16 designed proforma. After that, the data of all 6.0% 36.4% 16.0% patients was entered and analyzed in SPSS 60-69 6 3 9 version 16.00. The frequency and percentage 9.0% 9.1% 9.0% (%) was calculated for cardiac manifestations 70 + 6 2 8 in patients with pulmonary tuberculosis as far 9.0% 6.1% 8.0% as age and gender was concerned. The mean Total 67 33 100 and standard deviation (SD) was calculated for 100.0% 100.0% 100.0% numerical variables. The stratification was done Table-I. The age and gender distribution of patients with for age and gender in subjects with pulmonary tuberculosis tuberculosis. The chi-square test was applied (age and gender) and the statistical significance *P value <0.01 was considered on p-value ≤0.05. FINDINGS N = 72 %age RESULTS Sinus tachycardia 22 30.55 Total one hundred patients with pulmonary Sinus bradycardia 03 4.15 tuberculosis were evaluated for cardiac P-pulmonale 09 12.50 manifestation during six months study period. Prolonged PR interval 07 9.72 The mean ±SD for age of patients with pulmonary QRS low voltage complex 04 5.55 tuberculosis was 45.21±8.95. The mean age Left axis Deviation 06 8.33 ±SD of patient with cardiac manifestations was Right axis Deviation 05 6.94 48.95±5.53. The age in relation to gender and Prolonged QT interval 03 4.16 cardiac manifestations is shown in Table-I-III. The Premature ventricular beats 02 2.77 common presenting clinical features observed in Atrial Premature Complex 01 1.38 the study population were fever 90%, weight loss Multiple findings 10 13.88 70%, cough / haemoptysis 78%, chest pain and Table-II. Electrocardiographic changes observed in shortness of breath 75%, anorexia 83% and night patients with pulmonary tuberculosis Professional Med J 2015;22(6):733-737. www.theprofesional.com 734 PULMONARY TUBERCULOSIS 3 DISORDER N = 50 %age the cardiac function and identified pericardial LV systolic Dysfunction 04 08 effusion in 21 subjects in present study. All the Diastolic Dysfunction 02 04 patients were then placed on antituberculous Cardiac tamponade 08 16 regimen with steroids and were followed up, Pericardial effusion 21 42 showed complete resolution of the pericardial RV hypertrophy or dilation. 03 06 effusion in 18 subjects while the 03 patients Multiple abnormalities 12 24 need pericardicentesis. The cor-pulmonale was Table-III. Echocardiographic abnormalities detected also identified clinically and radiologically as in patients with pulmonary tuberculosis the subjects had bilateral pulmonary infiltrates and had physical signs i.e. raised JVP, left DISCUSSIONS parasternal heave, loud / palpable P2 and the In present study one hundred cases of sputum echocardiography showed right ventricular positive pulmonary tuberculosis without any enlargement. A study conducted by Agarwal BV, known heart disease were studied. The cardiac et al shown corpulmonale in 19 out of 125 cases involvement was seen in 72 out of 100 subjects whereas Padmavathi S, et al observed 32 out of with pulmonary tuberculosis on ECG whereas the 454 cases of corpulmonale due to pulmonary 50/72 (69.4%) patients had abnormal findings on tuberculosis.16,17 Four patients in the present echocardiography. Pericardial involvement in
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