Tuberculous myocarditis presenting as a refractory ventricular tachycardia of biventricular origin

Abstract

Ventricular tachycardia (VT) is one of the difficult clinical problems for the physician. Its evaluation and treatment are complicated because of its life-threatening nature and urgent need of rapid management.Any process that creates myocardial scar tissue could be the substrate for ventricular tachycardia. The coronary artery disease is the most common cause of myocardial scar. The dilated cardiomyopathies, hypertrophic cardiomyopathy, right ventricular dysplasia, Chagas disease, sarcoidosis, myocarditis including tubercular and other chronic granulomatous conditions and surgical incisions in the ventricle also can create myocardial scar and can lead to ventricular tachycardia. Occasionally, the arrhythmia may be well-tolerated, but in most of the situations it is associated with grave, life-threatening hemodynamic compromise. Regardless of the arrhythmia mechanism, the severity of clinical symptoms and hemodynamic compromise determines the urgency with which VT must be treated. Rarely, patients present with repetitive runs of nonsustained or sustained VT despite the medical treatment and poorly respond to the conventional treatment. Such refractory VT may cause a tachycardia-induced cardiomyopathy in long run. In such cases, long-term management also include looking beyond the VT and work up for the possible and treatable cause of VT. Here we are presenting a case report of a young patient with tubercular myocarditis who has presented to us with recurrent ventricular tachycardia of both right bundle and left bundle branch block morphology and LV dysfunction. A review of literature has been carried out on causes and management of refractory VT.

Patterns and clinical manifestations of tuberculous myocarditis: a systematic review of cases

“…An anatomical predilection for the right-sided mediastinal lymph nodes has been described in this condition, making the right side of the heart the most vulnerable area of the myocardium owing to the potential for contiguous spread [ 4 ]. Three distinct forms of myocardial involvement are recognized: nodular tubercles of the myocardium (characterized by central caseation); miliary tubercles of the myocardium (resulting from hematogenous spread); and an uncommon diffuse infiltrative type associated with tuberculous pericarditis (characterized microscopically by giant cells and lymphocytes) [ 5 , 6 ]. The myocardium may be involved by hematogenous spread, by retrograde lymphatic spread from mediastinal lymph nodes or by direct invasion from the pericardium [ 7 , 8 ].…”

Clinical Case: Tuberculous Myopericarditis in the Cardiology Practice

“…При этом аритмия не является характерным симптомом для изолированного туберкулезного перикардита [15,16], но при миокардите он встречается достаточно часто [17]. В литературе описано развитие блокады правой ножки пучка Гиса [18], полной атриовентрикулярной блокады [19], эктопического желудочкового ритма [20][21][22] при туберкулезном миокардите.…”

“…Так, в случае, описанном Khurana и соавт., пациенту с рефрактерной к медикаментозному лечению нарушений ритма сердца был имплантирован кардиовертер-дефибриллятор [22], а пациенту, описанному M.P. Gautan, была проведена электрическая кардиоверсия [21].…”

Ventricular arrhythmia: A feature of tubercular myocarditis

“…There are scantily described cases of the same. [123] It is important to recognize this rare entity.…”