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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 480-483

Sagittal venous thrombosis in disseminated tuberculosis: A rare presentation


Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University) ,Wardha, Maharashtra, India

Date of Submission21-Apr-2020
Date of Decision25-May-2020
Date of Acceptance30-Jun-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Mona Vohra
Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Sawangi, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_148_20

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  Abstract 


Sagittal venous thrombosis (SVT) is most commonly seen in hypercoagulable conditions, whereas infection-related thrombosis is very rare. Infections due to viruses, fungi, and bacteria can cause SVT. Disseminated tuberculosis (TB) causing SVT is rarely reported. Here, we report the case of a 38-year-old male who presented with the complaints of numbness and weakness to the right side of the body, cough with mucopurulent expectoration, and breathlessness. The patient was examined, which showed signs of cerebral inflammation and right-sided hemiparesis. Respiratory examination was suggestive of pulmonary TB. Chest X-ray was done which was suggestive of bilateral nodular opacities, and sputum Cartridge based nucleic acid amplification test (CBNAAT) was positive for Mycobacterium TB. Cerebrospinal fluid analysis was suggestive of tubercular meningitis. Magnetic resonance imaging brain was also done which revealed sagittal sinus thrombosis and bilateral frontoparietal cortical vein thrombosis and associated hemorrhagic infarct in the left parietal lobe. The patient was treated with antitubercular drugs along with anticoagulants.

Keywords: CBNAAT, cerebrospinal fluid, disseminated tuberculosis, magnetic resonance imaging, sagittal venous thrombosis


How to cite this article:
Ali S, Vohra M, Jadhav U, Ghewade B. Sagittal venous thrombosis in disseminated tuberculosis: A rare presentation. J Datta Meghe Inst Med Sci Univ 2020;15:480-3

How to cite this URL:
Ali S, Vohra M, Jadhav U, Ghewade B. Sagittal venous thrombosis in disseminated tuberculosis: A rare presentation. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 7];15:480-3. Available from: http://www.journaldmims.com/text.asp?2020/15/3/480/308546




  Introduction Top


Tuberculosis (TB) is a risk factor for the development of venous thromboembolism irrespective of the presence of other contributing factors. Disseminated TB is defined as the presence of two or more noncontiguous sites resulting from hematogenous dissemination of Mycobacterium TB, occurring as a result of progressive primary infection, reactivation of a latent focus with subsequent spread?,[1] or rarely through iatrogenic origin?.[2]

We report the case of a 38-year-old male who presented with sagittal venous thrombosis with disseminated TB.


  Case Report Top


A 38-year-old male presented with the complaints of numbness and weakness to the right side of the body for 2 months, low-grade evening rise of temperature for 2 months, and deviation of angle of mouth to the left side for 25 days. The patient also had a history of cough with mucopurulent expectoration and MMRC Grade 2 breathlessness for 25 days along with a history of 30 kg of weight loss. He was first admitted in a local private hospital where he was given NIV trial in view of tachypnea and falling saturation. Later as the patient's condition worsened, he was intubated and referred to a higher center on T-piece.

General examination

O2 saturation was 85% on T-piece with oxygen at 2 L/min, pulse – 124/min, relative risk – 34/min, and blood pressure – 110/70 mmHg. There was no pallor, cyanosis, clubbing, or lymphadenopathy. Arterial blood gas analysis was suggestive of respiratory acidosis.

Respiratory examination

The upper respiratory tract was normal. The lower respiratory tract revealed no obvious abnormalities on inspection, palpation, or percussion. Auscultation revealed bilateral coarse crepitation.

Neurological examination

The patient was responding to painful stimuli, spontaneous eye movements were present, bilateral reflexes were exaggerated, and the right plantar was mute, with neck rigidity +.

The provisional diagnosis was pulmonary TB with cerebral vascular infarct.

Chest X-ray posteroanterior view [Figure 1] was done which was suggestive of bilateral nodular opacities with left upper lobe haziness.

The patient was put on mechanical ventilation in view of respiratory distress. All routine investigations were done, which revealed raised total leukocyte count– of 15,400 cells/mm3 with neutrophilic leukocytosis, hemoglobin of 11.1 g%, platelet count of 87,000/mL, erythrocyte sedimentation rate of 65, random blood sugar of 78, normal liver function test, kidney function test, urine routine, serum homocysteine level of 55, sputum acid-fast bacillus negativity, sputum CBNAAT positivity, and nonreactive HIV test.
Figure 1: Chest X-ray posteroanterior view suggestive of bilateral nodular opacities and left upper lobe haziness

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Lumbar puncture was done which revealed high cerebrospinal fluid (CSF) counts of 150/mm3, predominantly 60% lymphocytes, ADA-18, CSF protein – 225, sugar – 45, lactate dehydrogenase – 270, and pH – 7.2.

CSF cytology revealed granular material and contaminants and rare leukocytic nuclear fragments. There was no pleocytosis.

Computed tomography brain [Figure 2] revealed hemorrhagic transformation of acute infarct in the left high frontoparietal region and centrum semiovale. Hyperdense superior sagittal sinus and cortical veins in the bilateral high frontoparietal region were suggestive of venous sinus thrombosis.
Figure 2: Computed tomography brain axial view suggestive of hemorrhagic acute infarct

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Magnetic resonance imaging brain [Figure 3],[Figure 4],[Figure 5] revealed sagittal sinus thrombosis throughout the length and bilateral frontoparietal cortical vein thrombosis and associated hemorrhagic infarct in the left parietal lobe. Small nonhemorrhagic venous infarct was noted in the right frontoparietal lobe.
Figure 3: Magnetic resonance imaging coronal view suggestive of sagittal venous thrombosis with hypoplastic right transverse sinus

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Figure 4: Magnetic resonance imaging sagittal view suggestive of cortical venous thrombosis

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Figure 5: Magnetic resonance imaging axial view suggestive of hemorrhagic infarct in the left parietal lobe

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The patient was given antitubercular treatment (ATT), injection dexamethasone for 15 days, and low-molecular-weight heparin along with Vitamin K analogs. The patient was extubated in view of the improving respiratory and central nervous system (CNS) parameters. International normalized ratio was maintained between 2 and 2.5. The patient's repeat chest X-ray was done which showed significant resolution [Figure 6], and there was significant clinical improvement. He was discharged on ATT and warfarin.
Figure 6: Chest X-ray posteroanterior view showing resolution

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  Discussion Top


Disseminated TB is characterized by a wide dissemination into the human body by the tiny size of the lesions (1–5 mm) in the lungs and possibly in other organs of the body, mostly liver, spleen, lymph nodes, pleura, pericardium, meninges, and bone marrow.[3] Tuberculous meningitis was first described by Willis in the 17th century, and it is the most severe form of TB. According to WHO statistics, five countries, namely, India, China, Pakistan, Indonesia, and South Africa, account for over 70% of the global burden of TB.[4] Very few patients are reported in the literature who have TB associated with cerebral venous thrombosis (CVT). Of the reported cases, two had disseminated TB with no involvement of CNS,[5] one had only pulmonary disease, and another had chronic granulomatous meningitis.[6] Stroke-like manifestations consequent to CVT have also been observed with tuberculous meningitis.[7]

Various pathophysiological processes are described in literature to explain the relation between TB and CVT, namely (1) injury to the endothelium, (2) alterations in normal blood flow, and (3) alterations in the blood coagulability. Blood stasis occurs because intracranial sinus is a low-pressure system without valves. Increased platelet aggregability is the cause of hypercoagulable state seen in patients with TB.[8]

Endothelial injury in intracranial veins may be the consequence of the same mechanism, which occurs in arterial vessels because of TB. Arteries running through the subarachnoid space may show obliterative endarteritis with inflammatory infiltrates in their walls, and marked intimal thickening. Another theory suggests that a transition G A at position 20210 is associated with elevated prothrombin concentration and thrombosis. People with mutation in this gene and presence of factor V Leiden mutation may have increased 5–10-fold risk of venous thrombosis.[8] However, both mutations when alone are not high risk factors for venous thrombosis.[9],[10],[11],[12],[13],[14],[15],[16],[17]


  Conclusion Top


CVT due to Mycobacterium TB is a rare occurrence. A very high index of suspicion is required to correctly diagnose the complication as its timely aggressive treatment results in an excellent outcome for the patient in the form of complete recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan FY, Dosa K, Fuad A, Ibrahim W, Alaini A, Osman L, et al. Disseminated tuberculosis among adult patients admitted to Hamad General Hospital, Qatar: A five year hospital based study. Mycobact Dis 2016;6:212.  Back to cited text no. 1
    
2.
Salem B. Disseminated tuberculosis following the placement of ureteral stents: A case repot. Cases J 2008;1:383.  Back to cited text no. 2
    
3.
Ghewade BD, Sharma T, Chaudhari S, Cladius S. Disseminated tuberculosis with splenic involvement in an immunocompetent host: A rare entity. Int J Med Sci Public Health 2016;5:1731-3.  Back to cited text no. 3
    
4.
WHO. Global Tuberculosis Control: WHO Report 2016. Report. Geneva: World Health Organization; 2016.  Back to cited text no. 4
    
5.
Kakkar N, Banerjee AK, Vasishta RK, Marwaha N, Deodhar SD. Aseptic cerebral venous thrombosis associated with abdominal tuberculosis. Neurol India 2003;51:128-9.  Back to cited text no. 5
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6.
Finsterer J, Kladosek A, Nagelmeier IE, Becherer A, Matula C, Stradal KH, et al. Chronic granulomatous meningitis with multiple cranial nerve lesions hydrocephalus, stroke, sinus thrombosis, and epilepsy. South Med J 2000;93:1108-11.  Back to cited text no. 6
    
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Fiorot Júnior JA, Felício AC, Fukujima MM, Rodrigues CA, Morelli VM, Lourenço DM, et al. Tuberculosis: An uncommon cause of cerebral venous thrombosis? Arq Neuropsiquiatr 2005;63:852-4.  Back to cited text no. 7
    
8.
Robson SC, White NW, Aronson I, Woollgar R, Goodman H, Jacobs P. Acute-phase response and the hypercoagulable state in pulmonary. Br J Hematol 1996;93:943-9.  Back to cited text no. 8
    
9.
Kurkowska-Jastrzebska I, Wicha W, Dowzenko A, Vertun-Baranowska B, Pytlewski A, Boguslawska R, et al. Concomitant heterozygous factor V Leiden mutation and homozygous prothrombin gene variant (G20210A) in patient with cerebral venous thrombosis. Med Sci Monit 2003;9:CS41-5.  Back to cited text no. 9
    
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Sharma SK, Mohan A. Extrapulmonary Tuberculosis. Mycobacterium Tuberculosis: Molecular Infection Biology, Pathogenesis, Diagnostics and New Interventions 2019. Available from: https://doi.org/10.1007/978-981-32-9413-4_4. [Last accessed on 2020 Feb 17].  Back to cited text no. 10
    
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Dakhode S, Muntode P, Gaidhane A. A Cross Sectional Assessment of Tuberculosis (Tb) Related Knowledge and Awareness among Urban Slum Dwellers in Wardha District. Indian J Public Health Res Dev 2019;10:165-70. Available from: https://doi.org/10.37506/v10/i12/2019/ijphrd/192684. [Last accessed on 2020 Feb 17].  Back to cited text no. 11
    
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Garg S, Vagha S, Khedkar SS. Correlation of Clinical Presentation, Histopathology and Polymerase Chain Reaction for Diagnosis of Genital Tuberculosis at Rural Hospital. Int J Pharm Res 2019;11:1198-202. Available from: https://doi.org/10.31838/ijpr/2019.11.01.212. [Last accessed on 2020 Feb 17].  Back to cited text no. 12
    
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Sharma SK, Chaubey J, Singh BK, Sharma R, Mittal A, Sharma A. Drug Resistance Patterns among Extra-Pulmonary Tuberculosis Cases in a Tertiary Care Centre in North India. Int J Tuberc Lung Dis 2017;21: 1112-7. Available from: https://doi.org/10.5588/ijtld.16.0939. [Last accessed on 2020 Feb 17].  Back to cited text no. 13
    
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Sharma SK, Dheda K. What Is New in the WHO Consolidated Guidelines on Drug-Resistant Tuberculosis Treatment? Indian J Med Res 2019;149: 309-12. Available from: https://doi.org/10.4103/ijmr.IJMR_579_19. [Last accessed on 2020 Feb 17].  Back to cited text no. 14
    
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Sharma SK, Mohan A. Extrapulmonary Tuberculosis. Mycobacterium Tuberculosis: Molecular Infection Biology, Pathogenesis, Diagnostics and New Interventions, 2019. Available from: https://doi.org/10.1007/978-981-32-9413-4_4. [Last accessed on 2020 Feb 17].  Back to cited text no. 15
    
16.
Sharma SK, Mohan A, Singh AD, Mishra H, Jhanjee S, Pandey RM, et al. Impact of Nicotine Replacement Therapy as an Adjunct to Anti-Tuberculosis Treatment and Behaviour Change Counselling in Newly Diagnosed Pulmonary Tuberculosis Patients: An Open-Label, Randomised Controlled Trial. Sci Rep 2018;8: 990-7. Available from: https://doi.org/10.1038/s41598-018-26990-5. [Last accessed on 2020 Feb 17].  Back to cited text no. 16
    
17.
Taksande A, Meshram R, Yadav P, Lohakare A. Rare Presentation of Cerebral Venous Sinus Thrombosis in a Child. J Pediatr Neurosci 2017 12:389-92. Available from: https://doi.org/10.4103/JPN.JPN_109_17. [Last accessed on 2020 Feb 17].  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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