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Subsequently&#44; he reported orthopnea&#44; exertional dyspnea and palpitation over the previous three months&#46; He developed shortness of breath at rest&#44; one day prior to admission&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On examination&#44; he had reduced air entry on the right side with bilateral basal crepitations&#46; Cardiac evaluation showed LVS3&#44; 3&#47;6 pan-systolic murmur at the mitral area&#46; Diagnostic pleural fluid work-up revealed straw-colored fluid&#44; 90 cells&#47;high-power-field &#40;95&#37; lymphocytes&#44; 5&#37; polymorphs&#41;&#46; The cartridge based nucleic acid amplification test of pleural fluid for MTB and blood culture were negative&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Echocardiographic evaluation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; demonstrated posterior mitral leaflet &#40;PML&#41; prolapse with thick-walled aneurysm in the submitral area&#59; cavity size 5&#46;1 &#215; 4&#46;0 cm with to and fro flow into the cavity&#44; with severe mitral regurgitation &#40;MR&#41;&#44; no vegetation and thin rim of pericardial effusion&#46; Cardiac contrast-enhanced CT-scan &#40;CECT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41; also showed aneurysmal dilatation at the base of the LV along the mitral annulus with prolapse of PML into the left atrium &#40;LA&#41;&#46; Both LA and LV were dilated&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was started on heart failure management&#46; He was re-initiated on ATT and underwent early mitral annular reconstruction with a tanned pericardial patch and MV replacement with &#35;25&#47;33 mm On-X mechanical prosthetic valve &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A&#8211;C&#41;&#46; Valve tissue on histopathological examination displayed necrotizing epithelioid cell granulomatous valvulitis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>D&#41; along with the growth of acid fast bacilli in culture&#44; suggestive of tuberculous etiology&#46; The patient had an uneventful postoperative recovery and is currently on ATT and oral anticoagulation and doing well&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Submitral aneurysm or postero-basal aneurysm is an unusual cardiac condition first described by Abrahams et al&#46; in patients of African origin&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Congenital weakening in the posterior section of the mitral fibrous annulus or a disjunction between the LV and LA muscles are two potential etiologies&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Infective diseases such as tuberculosis can very rarely lead to the development of submitral aneurysms&#44; as in our case&#46; Similar cases of tuberculous submitral aneurysm&#44; in which patients developed heart failure and succumbed following surgery have been reported rarely&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a> Presentation may be variable&#44; small aneurysms are asymptomatic&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> larger ones present with dyspnea caused by MR secondary to imperfect coaptation of the leaflets&#44; as in our patient&#46; They can also present with life-threatening ventricular arrhythmias&#44; thromboembolic phenomena&#44; compression of a coronary artery&#44; heart failure&#44; rupture leading to death&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Echocardiography and CECT are essential modalities for diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Early surgery is indicated in severe cases&#46; Histopathological examination after surgery clinched the etiology as tuberculous in our patient&#46; Proper compliance with anti-tuberculous medication must be ensured in these cases&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">Consent was obtained from the patient for the purpose of anonymized publication&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest&#46;</p></span></span>"
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Tuberculous submitral aneurysm: A rare cardiac presentation of a common pathogen
Aneurisma submitral tuberculoso: uma apresentação cardíaca rara de um patógeno comum
Usnish Adhikaria,
Autor para correspondência
adhikari.usnish1991@gmail.com

Corresponding author.
, Harikrishnan Sivadasanpillaia, Bineesh K. Radhakrishnanb, Mohamed Iliyasa
a Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Thiruvananthapuram, Kerala, India
b Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Thiruvananthapuram, Kerala, India
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Subsequently&#44; he reported orthopnea&#44; exertional dyspnea and palpitation over the previous three months&#46; He developed shortness of breath at rest&#44; one day prior to admission&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On examination&#44; he had reduced air entry on the right side with bilateral basal crepitations&#46; Cardiac evaluation showed LVS3&#44; 3&#47;6 pan-systolic murmur at the mitral area&#46; Diagnostic pleural fluid work-up revealed straw-colored fluid&#44; 90 cells&#47;high-power-field &#40;95&#37; lymphocytes&#44; 5&#37; polymorphs&#41;&#46; The cartridge based nucleic acid amplification test of pleural fluid for MTB and blood culture were negative&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Echocardiographic evaluation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; demonstrated posterior mitral leaflet &#40;PML&#41; prolapse with thick-walled aneurysm in the submitral area&#59; cavity size 5&#46;1 &#215; 4&#46;0 cm with to and fro flow into the cavity&#44; with severe mitral regurgitation &#40;MR&#41;&#44; no vegetation and thin rim of pericardial effusion&#46; Cardiac contrast-enhanced CT-scan &#40;CECT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41; also showed aneurysmal dilatation at the base of the LV along the mitral annulus with prolapse of PML into the left atrium &#40;LA&#41;&#46; Both LA and LV were dilated&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was started on heart failure management&#46; He was re-initiated on ATT and underwent early mitral annular reconstruction with a tanned pericardial patch and MV replacement with &#35;25&#47;33 mm On-X mechanical prosthetic valve &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A&#8211;C&#41;&#46; Valve tissue on histopathological examination displayed necrotizing epithelioid cell granulomatous valvulitis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>D&#41; along with the growth of acid fast bacilli in culture&#44; suggestive of tuberculous etiology&#46; The patient had an uneventful postoperative recovery and is currently on ATT and oral anticoagulation and doing well&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Submitral aneurysm or postero-basal aneurysm is an unusual cardiac condition first described by Abrahams et al&#46; in patients of African origin&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Congenital weakening in the posterior section of the mitral fibrous annulus or a disjunction between the LV and LA muscles are two potential etiologies&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Infective diseases such as tuberculosis can very rarely lead to the development of submitral aneurysms&#44; as in our case&#46; Similar cases of tuberculous submitral aneurysm&#44; in which patients developed heart failure and succumbed following surgery have been reported rarely&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a> Presentation may be variable&#44; small aneurysms are asymptomatic&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> larger ones present with dyspnea caused by MR secondary to imperfect coaptation of the leaflets&#44; as in our patient&#46; They can also present with life-threatening ventricular arrhythmias&#44; thromboembolic phenomena&#44; compression of a coronary artery&#44; heart failure&#44; rupture leading to death&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Echocardiography and CECT are essential modalities for diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Early surgery is indicated in severe cases&#46; Histopathological examination after surgery clinched the etiology as tuberculous in our patient&#46; Proper compliance with anti-tuberculous medication must be ensured in these cases&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">Consent was obtained from the patient for the purpose of anonymized publication&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest&#46;</p></span></span>"
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                            0 => "D&#46;G&#46; Abrahams"
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                      "titulo" => "Submitral aneurysm of the left ventricle"
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                            0 => "D&#46;K&#46; Baruah"
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ISSN: 08702551
Idioma original: Inglês
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