A 62 year old Chinese male was admitted for 2-month history of left sided hemiparesis. Brain imaging showed multiple lesions suspicious of brain metastases. Otherwise asymptomatic, he was noted to be febrile at 38 oC and hypotensive at 89/60mmHg since admission.
Past medical history included left chorioretinitis and latent tuberculosis (TB) one year ago.
A hunt was on for the primary cancer and concurrent infections. Blood investigations revealed pancytopenia and negative tests for tumour markers and Human Immunodeficiency Virus. Computed tomography demonstrated bilateral pyelonephritis, pulmonary ground glass opacities and bulky liver and spleen but no masses, bone marrow (BM) aspiration and lumbar puncture were both non-diagnostic. Blood, urine and sputum cultures were negative at 48 hours.
The patient was given broad-spectrum antibiotics (ceftriaxone, gentamicin, vancomycin) but remained febrile. He was increasingly frustrated. While awaiting endoscopy, he developed heart failure. Urgent echocardiography showed a large mitral valve (MV) vegetation; with abscess involving aortic valve (AV), and severe aortic regurgitation. This was surprising as he had no cardiac murmur nor stigmata of infective endocarditis (IE). Emergent surgery was performed to drain the abscesses and replace both AV and MV. Pericardial adhesions, MV vegetation with abscess involving aortic annulus and aorto-left ventricular fistula were noted intraoperatively. Acid fast bacilli (AFB) was seen on debrided MV tissues and cultures became positive for mycobacteria tuberculosis (MTC) after 19 days. Cultures from blood, endotracheal tube aspirate, urine and cerebrospinal fluid, eventually also returned positive for MTC.
The patient’s final diagnosis was disseminated TB with brain, endocardial, pulmonary and renal involvement. It accounted for all the abnormalities observed. He received a year of combination TB therapy and made a full recovery.
Tuberculosis is a re-emergent disease and can be difficult to diagnose, as in this case where the patient has multi-systemic disease and atypical presentation. He underwent a battery of inpatient tests, empirical treatments and had life-threatening heart failure; and the diagnostic uncertainty was a toll for both patient and hospitalist. In retrospect, TB should have been a differential for unremitting fever and pneumonia, especially with history of latent TB. But the multi-systemic involvement, endocarditis and initial negative cultures were barriers to early diagnosis. Cultures for MTC can take up to 8 weeks to become positive. Unless there is an awareness of this multi-faceted disease, and a methodical diagnostic approach, this contagious and curable disease could be missed.
This case highlights the unusual presentation and sites of involvement of tuberculosis. Prolonged fever and features of multisystem involvement should raise the suspicion of this old but re-emergent disease.
To cite this abstract:Chong C, Woong N, Kang M. Getting to the Heart of the Matter. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 486. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/getting-to-the-heart-of-the-matter/. Accessed January 22, 2020.