Introduction Miliary TBC represents a complex disease, quite rare at our latitudes. We present a case with severe pericardial involvement. Case report a 25-year-old Pakistani male, recently come in Italy, presented for fever and orthopnea. Anamnesis was difficult because of linguistic barrier. Echocardiogram revealed a large pericardial effusion with signs of tamponade, so a pericardiocentesis was promptly performed and exudative fluid was drained out and sent to laboratory. Blood tests showed anemia, mild hyponatremia, VES elevation and several vitamin deficiencies. Few days after the procedure the patient developed fever with chills, so blood samples for cultural tests were taken, but resulted negative. To better understand the etiology of pericardial effusion and fever a thoraco-abdominal CT was performed and bared multiple micronodular lesions disseminated to lungs, spleen and lever and pleural and peritoneal effusion. At the same time, the DNA search for Koch's bacillus in the pericardial fluid resulted positive for Mycobacterium TBC complex. So, a diagnosis of miliary TBC with pericardial involvement was done and corticosteroid therapy together with antitubercular drugs were started. Encephalic MRI excluded neurological involvement. Patient was isolated and moved to the infectious disease ward, where therapy was continued until recovery. Discussion Miliary TBC is a disseminated form due to the hematogenous spread of tubercle bacilli resulting in the formation of multiple tuberculous foci. This manifestation is more frequent in countries where TBC is still endemic (Pakistan, India, Philippines). The disease can progress slowly with few symptoms or acutely (typical of younger) and the identification may be challenging due to its rarity in developed countries and the lack of uniform criteria. Diagnosis is mainly based on the isolation mycobacterial from a specimen or molecular methods such as PCR. Treatment is based on standard antitubercular drugs regimen. The role of corticosteroids is still controversial. Conclusions Miliary TBC is a rare disease in developed countries with not well-defined diagnosis criteria and different clinical presentations. However, because of the increase of migration flows, is important to recognize this manifestation, especially when it develops acutely and with life-treating conditions such as pericardial tamponade.

Introduction Perioperative Takotsubo cardiomyopathy (pTC) represents a rare and still not well characterized disease. Biventricular involvement is an uncommon manifestation of TC and is associated with a more severe clinical presentation. Case report A 72-year-old male, hospitalized for a laparoscopic left hemicolectomy, was transferred to ICU after having developed severe bradycardia, treated with Adrenalin, and cardiogenic shock during induction of general anesthesia. EKG showed complete atrio-ventricular block, so a temporary PMK was placed. Troponin was raised. Echocardiogram showed severe biventricular disfunction (LVEF 25%, TAPSE 12 mm) with akinesia of medio-apical segments, suggesting a biventricular pTC. Also, there was a reduction of 3D LV longitudinal strain (- 5,8%), particularly of the medio-apical portion, and RV free wall longitudinal strain (- 11%). Coronary angiography resulted negative. Patient's hemodynamic was supported with Noradrenalin and a cycle of Levosimendan, allowing to reach stability. Further echocardiogram showed improvement of biventricular function and longitudinal strain values. Due to the persistency of atrio-ventricular block, a definitive PMK was placed. Patient was discharged after therapy optimization. Discussion pTC is a little-known disease, as incidence and etiology are not well definite. Literature suggests a relation between pTC and physical or emotional stress due to surgery to promote an increase of catecholamine release. Other potential factors may be inadequate depth of anesthesia or tracheal manipulation during intubation and catecholaminergic drugs administration. On the other hand, the use of anesthetic volatile agents seems to have a cardioprotective effect. PTC is more common during general anesthesia and when occurs intraoperatively has a worse clinical presentation. Biventricular involvement, which is a rare and severe manifestation of TC, has been reported frequently among pTC patients. To date, due to the lack of a systematic review, there is little knowledge about potential risk factors, prevention strategies and management of pTC. Conclusions Despite multiple cases of pTC have been reported, several characteristics of this entity are not fully understood. However, it must be considered as a part of differential diagnosis in patients with anaesthesia-related decompensation. Biventricular involvement represents an infrequent presentation and its commonly associated with life-threating hemodynamic impairment.