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Asian Cardiovasc Thorac Ann 2002;10:362-364
© 2002 Asia Publishing EXchange Pte Ltd

CASE STUDY

Cardiac Operation With Associated Pulmonary Resection: a Word of Caution

Calvin SH Ng, MBBS, Ahmed A Arifi, MD, Wan Song, MD, Lee Tak Wai, MD, Anthony PC Yim, MD

Division of Cardiothoracic Surgery Department of Surgery The Chinese University of Hong Kong Prince of Wales Hospital Shatin, New Territories, Hong Kong People‘s Republic of China
For reprint information contact: Ahmed A Arifi, MD Tel: 352 2632 2629 Fax: 852 2637 7974 email: Arifiahmed{at}hotmail.com Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, People‘s Republic of China.

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
Pulmonary tuberculosis reactivation is an unusual cause of respiratory failure after cardiac surgery. Fulminating tuberculosis was reactivated in a 50-year-old man after combined coronary artery bypass grafting and pulmonary resection on cardiopulmonary bypass. Clinicians should be aware of the immunosuppressive effects associated with cardiopulmonary bypass, and the consequent potential for tuberculosis reactivation.


   INTRODUCTION
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 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Pulmonary tuberculosis (TB) is an important problem affecting almost one-third of the global population, which has recently reemerged worldwide. People with a compromised immune system, such as patients infected with human immunodeficiency virus, those on immunomodulation therapy, the poorly nourished, and the elderly are particularly at increased risk of TB infection and reactivation.1,2 Major surgery and trauma have also been found to cause delayed postoperative or post-injury immunosuppression.3 In particular, the early inflammatory and late immunosuppressive responses associated with cardiopulmonary bypass (CPB) may contribute to this reactivation process.


   CASE REPORT
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 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 50-year-old man with a history of ischemic heart disease, on-and-off exertional angina, and previous coronary angioplasty, was referred for coronary artery bypass grafting due to recent deterioration of symptoms. He was a chronic smoker with hypertension and type II diabetes. Coronary angiography detected significant lesions in the left anterior descending and circumflex arteries. Preoperative chest radiography showed a left upper zone well-circumscribed calcified lung shadow that had been radiologically static for 10 years (Figure 1AGo). He had no respiratory symptoms or confirmed history of TB, and repeated sputum acid-fast bacilli tests were negative before surgery. Combined coronary revascularization on CPB and left lung wedge resection were performed uneventfully. The patient was extubated 8 hours postoperatively, and discharged from the intensive care unit next day. He experienced progressive breathlessness on the 3rd postoperative day. His oxygen saturation dropped to 84% on room air. A small left pleural effusion and increased left upper zone shadowing were noted on a chest radiograph. Despite high-flow oxygen therapy, oxygen saturation was low so he was readmitted to the intensive care unit and intubated (Figure 1BGo). A pleural drain was inserted and broad-spectrum antibiotics were started empirically. A leukocyte count was normal. On the following day, chest radiography showed extensive areas of consolidation in the left lung and right hilar region. Pathology of the resected lung wedge showed multiple calcified granulomas and acid-fast bacilli. Anti-TB chemotherapy with rifampicin, pyrazinamide, and isoniazid was commenced immediately. Tracheal aspirates and sputum cultures obtained before anti-TB treatment subsequently grew mycobacterium tuberculosis. The patient‘s condition gradually improved on anti-TB therapy, ventilatory support was stopped on postoperative day 15, and he was discharged on day 22. He has been closely followed up after completing 6 months of anti-TB therapy, and was in excellent condition 15 months after the operation.




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  		Figure 1. Chest radiographs (A) before surgery, and (B) on postoperative day 4 with fulminating pulmonary tuberculosis.

 

   DISCUSSION
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 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
Reactivation of TB following a latent infection is not uncommon. Although active TB can develop soon after being infected, the potential for reactivation remains for life. Immunosuppression following surgical trauma is a recognized phenomenon. Patients exhibit a physiological response to the injury postoperatively with an early phase of hyper-inflammation and a late phase of immunosuppression.3 These changes involve release of chemokines and complement, and altered function of the cells of the immune system. Cytokines such as interleukin (IL)-6 and IL-10 may play pivotal roles in the immunosuppressive response.3,4 Coronary artery bypass on CPB is likely to produce a significant immuno-suppressive effect at least partially induced by these two cytokines. It has been suggested that postoperative serum IL-6 levels are directly related to the degree of surgical trauma.3–5 The IL-6 levels may be inversely proportional to postoperative cellular immune function.3 The likelihood of postoperative nosocomial infection is also related to high levels of IL-6.3 Coronary artery bypass on CPB is also associated with enhanced production of IL-10 compared to the off-pump approach.5 Hence, CPB appears to trigger an additional release of IL-10. The immunosuppressive effects of IL-10 may be particularly important in tuberculosis patients.5 The combination of major surgery, cardiopulmonary ischemia, and CPB is likely to have contributed significantly to the postoperative immunosuppressed status of our patient, resulting in TB reactivation. In addition, concomitant resection of the lung nodule may have facilitated the reactivation of TB by disturbing the granulomas.

Although it remains unclear whether this TB reactivation was related to the surgical insult, CPB, or both, one should have a high index of suspicion for pulmonary tuberculosis infection or reactivation in patients with a history of TB presenting with delayed postoperative respiratory failure following CPB. The immunosuppressive effects of major surgery and CPB should not be underestimated, particularly in those with a possible underlying infectious disease undergoing combined cardiac and pulmonary resection procedures on CPB.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Daley CL, Small PM, Schecter GF, Schoolnik GK, McAdam RA, Jacobs WR Jr, et al. An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus. An analysis using restriction-fragment-length polymorphisms. N Engl J Med 1992;326:231–5.[Abstract]

  2. Munoz P, Palomo J, Munoz R, Rodriguez-Creixems M, Pelaez T, Bouza E. Tuberculosis in heart transplant recipients. Clin Infect Dis 1995;21:398–402.[Medline]

  3. Biffl WL, Moore EE, Moore FA, Peterson VM. Interleukin-6 in the injured patient. Marker of injury or mediator of inflammation? Ann Surg 1996;224:647–64.[Medline]

  4. Wan S, LeClerc JL, Vincent JL. Cytokine responses to cardiopulmonary bypass: lessons learned from cardiac transplantation. Ann Thorac Surg 1997;63:269–76.[Abstract/Free Full Text]

  5. Boussiotis VA, Tsai EY, Yunis EJ, Thim S, Delgado JC, Dascher CC, et al. IL-10-producing T cells suppress immune responses in anergic tuberculosis patients. J Clin Invest 2000;105:1317–25.[Medline]





This Article
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Song Wan
Anthony PC Yim
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Right arrow Articles by Ng, C. S.
Right arrow Articles by Yim, A. P.
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Right arrow Articles by Ng, C. S.
Right arrow Articles by Yim, A. P.
Related Collections
Right arrow Coronary disease
Right arrow Extracorporeal circulation

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