Imaging Findings in Tuberculous Heart Disease.

Abstract

HomeRadioGraphicsVol. 40, No. 2 PreviousNext Letters to the EditorFree AccessImaging Findings in Tuberculous Heart DiseaseMunish Dev , Madhurima SharmaMunish Dev , Madhurima SharmaAuthor AffiliationsDepartment of Cardiology, Apex Heart Institute, Mondeal Business Park, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India 380059Department of Radiology, Imaging World Diagnostic Center, Ahmedabad, Gujarat, Indiae-mail: [email protected]Munish Dev Madhurima SharmaPublished Online:Mar 3 2020https://doi.org/10.1148/rg.2020190216MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked InEmail Editor:We read with great interest the article “Extrapulmonary Tuberculosis: Pathophysiology and Imaging Findings” (1) published in the November-December 2019 issue of RadioGraphics. We would like to congratulate the authors for a comprehensive review of pathophysiology and imaging features in the various extrapulmonary manifestations of tuberculosis (TB). We agree with the authors that knowledge about organ-specific imaging features can help in the diagnosis of TB.The authors did not mention cardiac involvement in TB. In terms of morbidity and mortality, tuberculous involvement of the heart is second only to central nervous system TB among all of the extrapulmonary manifestations of TB (2). Hence, we believe that a review of the imaging manifestations of extrapulmonary TB would be incomplete without discussion of tuberculous heart disease. Tuberculous heart disease can manifest in three forms: tubercular pericarditis, myocarditis, and aortitis, of which pericarditis is the most common form (2).Pericardial involvement in extrapulmonary TB can have three manifestations: pericardial effusion, constrictive pericarditis, or a combination of the two (3). In developing countries, 40%–70% of large pericardial effusions are tubercular in origin, and TB is the most common cause of constrictive pericarditis (2). Associated constitutional symptoms and evidence of concurrent TB elsewhere in the body help in making a diagnosis of pericardial TB (2). Although echocardiography is the initial imaging modality used in cases of suspected pericardial effusion, CT and MRI are useful in demonstrating associated loculations and pericardial thickening (4). Cross-sectional imaging also has the advantage of demonstrating additional findings in the mediastinum and lungs that can point toward a tubercular cause. CT has the advantage of demonstrating pericardial calcification, which is frequently associated with constrictive pericarditis (4).Myocardial involvement in TB is extremely rare. Three forms of myocardial TB have been described: the miliary form, the diffuse infiltrative form, and tuberculoma formation (5). At MRI, cardiac tuberculosis demonstrates T2 shortening similar to that seen with intracranial tuberculomas (5). This finding aids in its differentiation from other myocardial masses such as metastases and angiosarcoma, which are hyperintense on T2-weighted images.Tuberculous aortitis usually involves the distal aortic arch and descending thoracic aorta and is usually due to contiguous spread from adjacent mediastinal lymphadenopathy, empyema, or paraspinal abscess (6). Aortic aneurysms in TB are usually pseudoaneurysms with saccular morphology. When associated with a cold abscess, these aneurysms have an increased risk of perforation (6). CT angiography is the imaging modality of choice for demonstrating aortic involvement in extrapulmonary TB.