Pulmonary vein compression by paravertebral abscess: An atypical presentation of tuberculosis

Debabrata Bera; Biswajit Majumder; Deepesh Venkatraman; Monika Bhandari

doi:10.4103/0189-7969.148489

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CASE REPORT

Year : 2015 | Volume : 12 | Issue : 1 | Page : 51-53

Pulmonary vein compression by paravertebral abscess: An atypical presentation of tuberculosis

Debabrata Bera, Biswajit Majumder, Deepesh Venkatraman, Monika Bhandari
Department of Cardiology, RG Kar Medical College, Kolkata, West Bengal, India

Date of Web Publication

5-Jan-2015

Correspondence Address:
Debabrata Bera
Department of Cardiology, RG Kar Medical College, Kolkata, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0189-7969.148489

Abstract

Tuberculosis is a common disease in developing countries. It can cause dyspnea due to primary involvement of lungs with pulmonary Koch's, but one of the uncommon presentations may be solely due to compression of pulmonary veins (PVs) and/or left atrium resulting in exertional dyspnea resembling cardiac disease. Though there are case reports of lung metastasis, pulmonary artery aneurysm and left atrial myxoma causing PV compression, in literature PV compression due to cold abscess is extremely rare. Here, we report a case of paravertebral cold abscess causing symptoms effectively due to PV compression who got cured with anti-tubercular therapy.

Keywords: Paravertebral abscess, pulmonary vein compression, tuberculosis

How to cite this article:
Bera D, Majumder B, Venkatraman D, Bhandari M. Pulmonary vein compression by paravertebral abscess: An atypical presentation of tuberculosis. Nig J Cardiol 2015;12:51-3

How to cite this URL:
Bera D, Majumder B, Venkatraman D, Bhandari M. Pulmonary vein compression by paravertebral abscess: An atypical presentation of tuberculosis. Nig J Cardiol [serial online] 2015 [cited 2023 May 30];12:51-3. Available from: https://www.nigjcardiol.org/text.asp?2015/12/1/51/148489

Introduction

Tuberculosis (TB) is a common disease in developing countries. It can involve almost any organ of our body. Though TB usually presents with fever, cough, hemoptysis or weight loss, it can also cause dyspnea most commonly due to lung parenchymal involvement. But one of the rarer causes of dyspnea could be due to pulmonary vein (PV) compression by pulmonary nodule or paravertebral abscess, as in our index case. Though there are case reports of lung metastasis, ^[1] pulmonary artery aneurysm ^[2],[3] and left atrial myxoma ^[4] causing PV compression, in literature PV compression due to cold abscess is extremely rare. Here, we report a case of paravertebral cold abscess causing symptoms effectively due to PV compression who got cured with antitubercular therapy.

Case report

A 28-year-old female presented to our outpatient department (OPD) with a history of dyspnea on exertion since 2 months prior to presentation. She also had complaints of cough and occasional fever and significant weight loss over the last 5 months, but did not have any history of chest pain, hemoptysis or paroxysmal nocturnal dyspnea. There was a positive family history of TB, which might be the source of infection in her case. Her physical finding did not reveal any abnormalities on systemic examination except mild pallor. There were no abnormal findings on respiratory system examination. The chest X-ray as documented on OPD card was unremarkable antitussive medications. She was treated with multiple antibiotics and antitussive. Her pulmonary function test was also normal. As her symptoms of cough and dyspnea persisted she was worked up for TB, but sputum examination and Mantoux test were negative. Complete hemogram was unremarkable except for increased erythrocyte sedimentation rate (62 mm in 1 ^st hr), her retroviral status was negative. Thus, she was referred to cardiology for evaluation after 2 months. Her cardiovascular system examination was normal. Her electrocardiography was also normal. ^[2]

On echocardiographic examination, her systolic and diastolic function were normal, but it revealed a peculiar flow within the left atrium (LA) which after proper evaluation was found to be because of compression of the left upper and lower PVs by an extracardiac mass, which has also started to compress the LA form outside [Figure 1]. The extracardiac mass appeared cystic and 7 × 8 cm in size in front of the spine.

Figure 1: Echocardiography showing extracardiac mass (cystic SOL) compressing the left atrium and left upper and lower pulmonary veins with pulmonary venous flow abnormality. (a) Parasternal long axis view (PLAX) showing the colour doppler image of the turbulent flow of the pulmonary vein inflow into the left atrium, with a SOL related posteriorly to LA (b) Apical Four chamber view showing the SOL in relation with LA (c) Continuous doppler at the Pulmonary inflow area in the PLAX view (d) Pulmonary vein draining into LA with turbulence with the SOL related posteriorly

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Suspecting a pulmonary or a pleural mass, CXR was repeated which showed a mediastinal mass with mediastinal widening more on the left side [Figure 2]a, also seen as a soft tissue shadow in the lateral film in relation to the LA [Figure 3]. Contrast-enhanced computed tomography chest was planned which revealed a paravertebral abscess probably a cold abscess [Figure 2]b. As it was not clear from the computed tomography (CT) thorax whether the PVs are being compressed or not, cardiac catheterization was performed. The results showed the left ventricular end-diastolic pressure was normal (10 mm of Hg), but pulmonary capillary wedge pressure (PCWP) as measured in the left lung, was elevated (21 mm of Hg). We also found that the PCWP as measured on the right side was within the normal limits. This supported our suspicion of PV compression especially on the left side. Although there was compression of PV by para vertebral abscess, there were no signs of compression of the spine.

Figure 2: (a) Chest X-ray showing the mediastinal mass visible more on the left side. (b) Computed tomography thorax showing the paravertebral abscess in the axial plane

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Figure 3: Lateral view of the X-ray chest showing a well-defined marginated mass in the posterior mediastinum in relation to the left atrial shadow

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A CT guided fine-needle aspiration cytology of the mass was then planned. It showed adenosine deaminase levels was high (116 IU/ml) with acid-fast bacillus positive.

She was diagnosed to have Pott's spine with cold abscess and treated with anti-tubercular drugs (ATD) according to DOTS (directly observed treatment strategy, Category 1) along with restricted mobilization for initial 3 months. She improved symptomatically within 2 weeks of starting of ATD and her CXR after 3 months showed a reduction in size of the abscess. Her serial echocardiographic examination showed gradually reducing compression with improving flow from the compressed left PVs and resolution of PV compression within 8 weeks. Her chest CT was repeated after 9 months, which showed complete resolution of the cold abscess [Figure 4]. Her lung parenchyma remained normal in both the CT scans.

Figure 4: Contrast enhanced computed tomography chest mediastinal window showing the resolution of the mass posttreatment

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Discussion

Tuberculosis can involve any organ of the body. Cough, fever, hemoptysis along with weight loss and are the usual presentation when lung parenchyma gets involved, whereas when it affects the spine it usually present with orthopedic/neurological complications. Here, our index case presented to us with respiratory complaints which were due to PV compression by the tubercular cold abscess in paravertebral area without any spinal compression. Initially, it was missed due to normal CXR when the cold abscess was smaller in size. But when diagnosed and thus treated with ATD, there was prompt improvement. It was also learnt that echocardiography is not only valuable for intracardiac problems, but also can give us a significant clue to extracardiac diseases, when properly performed.

In the literature, there are case reports of lung metastasis ^[1] and pulmonary artery aneurysm ^[2],[3] causing PV compression. A case reported by Biasucci et al. ^[4] showed effective PV inflow abnormalities in obstructive LA myxoma. There are no case reports for paravertebral cold abscess causing dyspnea due to PV compression. All these abnormalities actually cause symptoms due to effective PV stenosis. They present with dyspnea on exertion and cough as our index case did. When suspected, with proper evaluation and management, this reversible cause can be well cured.

Hence, the key message that evolves out of this case is although the most common cause of dyspnea in TB is pulmonary parenchymal involvement, TB can cause dyspnea solely due to PV compression by cold abscess. If it is diagnosed and treated properly, the cause is completely reversible and curable.

References

1.	Chen CL, Tunick PA, Kronzon I. Pulmonary vein compression by tumor: An unusual Doppler flow pattern. Echocardiography 2005;22:746-7.
2.	Decuypere V, Delcroix M, Budts W. Left main coronary artery and right pulmonary vein compression by a large pulmonary artery aneurysm. Heart 2004;90:e21.
3.	Kremser C, Cajulis R, Glagov S. Pulmonary vein and superior vena cava obstruction due to expanding aneurysm of the pulmonary artery. Chest 1988;93:206-7.
4.	Biasucci LM, De Benedittis G, Alecce G, Lombardo A, Loperfido F. Doppler analysis of pulmonary venous flow in left atrial myxoma. Chest 1994;105:315-7.