Heart & Lung 43 (2014) 158e160
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Care of Patients with Complications of Infectious Disease
Cardiac tuberculoma presenting as thrombotic thrombocytopenic purpura-hemolytic uremic syndrome Raza Askari, MD, Rami N. Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI * Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 October 2013 Received in revised form 3 November 2013 Accepted 3 November 2013 Available online 4 December 2013
Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a unique multisystem syndrome. It can present with either chronic or subacute infections. Tuberculosis (TB) is a chronic infection that has been reported to present with TTP-HUS as tuberculous endocarditis in the presence of immunodeficiency and implanted medical devices in regions where TB is endemic. Tuberculomas are space occupying lesions most commonly found in the brain in immunocompromised individuals. Herein, we present a rare association of tuberculosis with endocarditis manifesting as a tuberculoma and presenting as TTP-HUS in an immunocompetent patient and resident of the United States. Ó 2014 Elsevier Inc. All rights reserved.
Keywords: Cardiac tuberculoma Thrombotic thrombocytopenic purpura Left atrial mass
Case report A 25-year-old AfricaneAmerican female presented to the emergency room with multiple complaints, including episodes of nausea and vomiting for two months together with confusion and short-term memory loss for a week. She had a 4.5 kg unintentional weight loss over the preceding two months. She also reported intermittent paresthesias, visual changes that included blurred vision and “floaters,” fever and night sweats over a period of two months. Examination on admission was significant for elevated body temperature (38 C) and pulse rate of 110/min. Cardiovascular examination was negative for any murmurs and there was no jugular venous distention or pedal edema; skin examination did not reveal any rash. Neurologic examination was unremarkable except that she was only oriented to person, but not to time or place. Past medical history was significant for a “pericardial effusion” which she reported was treated with pericardiocentesis at age 9. Family history was remarkable as her father was diagnosed with active tuberculosis (TB) when the patient was 6 years old; the family had been evaluated, but no treatment was recommended. Neither the patient nor her father had ever traveled outside the US. Laboratory examination was significant for a leukocyte count of 3.6 k/mm3 (differential counts included 32% neutrophils, 38% bands, 20% lymphocytes and 10% monocytes), hematocrit of 26.9% (normal 35e45%), platelet count of 20,000 (normal 150,000e * Corresponding author. 1614 Dogwood Creek Dr., Germantown, TN 38120, USA. Tel.: þ1 901 747 5805, þ1 516 780 3762 (cell); fax: þ1 901 747 5805. E-mail address: [email protected] (R.N. Khouzam). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2013.11.001
450,000) and serum creatinine of 1.4 mg/dL (normal 0.7e1.3 mg/ dL). Review of medical records from a previous year showed a leukocyte count of 7.3 k/mm3, hematocrit of 39%, platelets 360,000 and creatinine 0.8 mg/dL. Further laboratory evaluation revealed schistocytes on her peripheral smear, an elevated lactate dehydrogenase of 682 (91e180 IU/L) and an undetectable haptoglobin of
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Care of Patients with Complications of Infectious Disease
Cardiac tuberculoma presenting as thrombotic thrombocytopenic purpura-hemolytic uremic syndrome Raza Askari, MD, Rami N. Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI * Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 October 2013 Received in revised form 3 November 2013 Accepted 3 November 2013 Available online 4 December 2013
Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a unique multisystem syndrome. It can present with either chronic or subacute infections. Tuberculosis (TB) is a chronic infection that has been reported to present with TTP-HUS as tuberculous endocarditis in the presence of immunodeficiency and implanted medical devices in regions where TB is endemic. Tuberculomas are space occupying lesions most commonly found in the brain in immunocompromised individuals. Herein, we present a rare association of tuberculosis with endocarditis manifesting as a tuberculoma and presenting as TTP-HUS in an immunocompetent patient and resident of the United States. Ó 2014 Elsevier Inc. All rights reserved.
Keywords: Cardiac tuberculoma Thrombotic thrombocytopenic purpura Left atrial mass
Case report A 25-year-old AfricaneAmerican female presented to the emergency room with multiple complaints, including episodes of nausea and vomiting for two months together with confusion and short-term memory loss for a week. She had a 4.5 kg unintentional weight loss over the preceding two months. She also reported intermittent paresthesias, visual changes that included blurred vision and “floaters,” fever and night sweats over a period of two months. Examination on admission was significant for elevated body temperature (38 C) and pulse rate of 110/min. Cardiovascular examination was negative for any murmurs and there was no jugular venous distention or pedal edema; skin examination did not reveal any rash. Neurologic examination was unremarkable except that she was only oriented to person, but not to time or place. Past medical history was significant for a “pericardial effusion” which she reported was treated with pericardiocentesis at age 9. Family history was remarkable as her father was diagnosed with active tuberculosis (TB) when the patient was 6 years old; the family had been evaluated, but no treatment was recommended. Neither the patient nor her father had ever traveled outside the US. Laboratory examination was significant for a leukocyte count of 3.6 k/mm3 (differential counts included 32% neutrophils, 38% bands, 20% lymphocytes and 10% monocytes), hematocrit of 26.9% (normal 35e45%), platelet count of 20,000 (normal 150,000e * Corresponding author. 1614 Dogwood Creek Dr., Germantown, TN 38120, USA. Tel.: þ1 901 747 5805, þ1 516 780 3762 (cell); fax: þ1 901 747 5805. E-mail address: [email protected] (R.N. Khouzam). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2013.11.001
450,000) and serum creatinine of 1.4 mg/dL (normal 0.7e1.3 mg/ dL). Review of medical records from a previous year showed a leukocyte count of 7.3 k/mm3, hematocrit of 39%, platelets 360,000 and creatinine 0.8 mg/dL. Further laboratory evaluation revealed schistocytes on her peripheral smear, an elevated lactate dehydrogenase of 682 (91e180 IU/L) and an undetectable haptoglobin of
