Characteristics of sternal mycobacterium tuberculosis infection after cardiac surgery: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Zhihua , HU Junlong , ZHAO Zeyuan , SUN Junjie , LI Zhao , XUAN Jizhong ,  CHENG Zhaoyun

Department of Cardiac Surgery, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 451464, P. R. China;

Corresponding author：

CHENG Zhaoyun, Email: Chengzhy@zzu.edu.cn

Keywords：

Cardiac surgery; sternal tuberculosis; mycobacterium tuberculosis; infection; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202307068

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Objective To analyze the characteristics of sternal Mycobacterium tuberculosis (Mtb) infection after cardiac surgery. Methods An electronic search was conducted for publicly available cases of sternal Mtb infection after cardiac surgery in PubMed, Web of Science, Wanfang database, and CNKI since their inception up to 18 July 2023, and 2 researchers analyzed the characteristics of the included cases and extracted relevant data. Results A total of 26 patients were included in 15 studies, 16 males and 10 females, aged 5-80 (61.9±15.6) years. Previous surgical history included coronary artery bypass grafting in 14 cases (53.8%), valve surgery in 8 cases (30.8%), congenital heart surgery in 3 cases (11.5%), and aortic surgery in 2 cases (7.7%). The main symptoms and signs were incisional abscesses, poor healing, mostly with pain, with or without erythema, and usually without systemic symptoms such as low-grade fever, night sweats, and weight loss. 13 cases reported a postoperative time to discovery of infection with a mean of 11.8 (0.5-60) months, and 9 cases reported an interval between discovery of infection and diagnosis with a mean of 12.1 (1.5-62) months. Confirmation of the diagnosis was mainly by Mtb culture of cleared bone tissue or pus, pathology and antacid staining. One case died of cardiac arrest before diagnosis. After the diagnosis of 25 cases, 13 cases received only anti-tuberculosis treatment, of which 11 cases received surgical treatment before diagnosis; 12 cases received anti-tuberculosis and surgical treatment, and all 25 cases were successfully cured. The duration of anti-tuberculosis treatment ranged from 6 to 12 months. Conclusion Sternal Mtb infection after cardiac surgery has a long incubation period, early diagnosis is difficult, the rate of missed diagnosis and misdiagnosis is extremely high, and timely diagnosis and treatment can significantly improve the prognosis.

1.	Parolari G, Sepulcri C, Salsano A, et al. Mycobacterium tuberculosis surgical site infection after cardiac surgery in the COVID-19 era: A case report. Infect Dis Rep, 2022, 14(1): 101-105.
2.	Rahlwes KC, Dias BRS, Campos PC, et al. Pathogenicity and virulence of mycobacterium tuberculosis. Virulence, 2023, 14(1): 2150449.
3.	Fujiwara T, Yanai H, Hagiya H. Like a shot-through manubrium: A rare presentation of skeletal tuberculosis. Clin Case Rep, 2023, 11(5): e7119.
4.	Rizzo V, Salmasi Y, Hunter M, et al. Delayed diagnosis of chronic postoperative sternal infection: A rare case of sternal tuberculosis. BMJ Case Rep, 2018: bcr2017223650.
5.	Hamada K, Oishi K, Uehara S, et al. Deep sternal wound tuberculosis with hypo-gamma-globulinemia. Intern Med, 2018, 57(17): 2563-2566.
6.	崔振田, 高永顺, 陆龙. 心脏手术后胸骨感染合并结核杆菌感染11例治疗体会. 中华胸心血管外科杂志, 2018, 34(5): 296-297.
7.	Tabaja H, Hajar Z, Kanj SS. A review of eleven cases of tuberculosis presenting as sternal wound abscess after open heart surgery. Infect Dis (Lond), 2017, 49(10): 721-727.
8.	Kim HJ, Kim JB, Chung CH. Chronic sternum wound infection caused by mycobacterium tuberculosis after cardiac surgery. Ann Thorac Surg, 2012, 94(4): 1332-1335.
9.	Patel P, Tabasi S. Sternal osteomyelitis caused by mycobacterium tuberculosis after open heart surgery. Infect dis clin prac, 2011, 19(5): 359-361.
10.	Kestler M, Reves R, Belknap R. Pacemaker wire infection with Mycobacterium tuberculosis: A case report and literature review. Int J Tuberc Lung Dis, 2009, 13(2): 272-274.
11.	Wang TK, Wong CF, Au WK, et al. Mycobacterium tuberculosis sternal wound infection after open heart surgery: A case report and review of the literature. Diagn Microbiol Infect Dis, 2007, 58(2): 245-249.
12.	Gopal K, Raj A, Rajesh MR, et al. Sternal tuberculosis after sternotomy for coronary artery bypass surgery: A case report and review of the literature. J Thorac Cardiovasc Surg, 2007, 133(5): 1365-1366.
13.	Rivas P, Górgolas M, Gimena B, et al. Sternal tuberculosis after open heart surgery. Scand J Infect Dis, 2005, 37(5): 373-374.
14.	Achouh P, Aoun N, Hagege A, et al. Mediastinitis due to Mycobacterium tuberculosis after a redo open heart surgery. J Cardiovasc Surg (Torino), 2005, 46(1): 93-94.
15.	Sipsas NV, Panayiotakopoulos GD, Zormpala A, et al. Sternal tuberculosis after coronary artery bypass graft surgery. Scand J Infect Dis, 2001, 33(5): 387-388.
16.	Aggarwal B, Kamath S, Shatapathy P. Tubercular sternal osteomyelitis and mediastinitis after open heart surgery. Indian Heart J, 1997, 49(3): 313-314.
17.	Rubinstien EM, Lehmann T. Sternal osteomyelitis due to mycobacterium tuberculosis following coronary artery bypass surgery. Clin Infect Dis, 1996, 23(1): 202-203.
18.	Jauhary T, Hayati F. Unusual sites of tuberculosis mimicking skeletal metastases: A case report. Radiol Case Rep, 2022, 17(6): 2898.
19.	Chakaya J, Petersen E, Nantanda R, et al. The WHO Global Tuberculosis 2021 Report - not so good news and turning the tide back to End TB. Int J Infect Dis, 2022, 124 Suppl 1: S26-S29.
20.	Bains L, Lal P, Chand T, et al. Isolated primary cold abscess of the sternum: A case report. J Med Case Rep, 2019, 13(1): 267.
21.	Yuan SM. Sternal mycobacterial infections. Ann Thorac Med, 2016, 11(2): 103-111.
22.	Kabiri EH, Alassane EA, Kamdem MK, et al. Tuberculous cold abscess of the chest wall: A clinical and surgical experience. Report of 16 cases(Case series). Ann Med Surg (Lond), 2020 Feb 13: 51: 54-58.
23.	Abe T, Hanawa H, Fujii Y. Gene expression of inflammatory cytokines in major organs by extracorporeal circulation. J Clin Med, 2023, 12(8): 2813.
24.	Al-Ebrahim KE. A unique spectrum of tuberculosis flare up related to cardiothoracic surgery. Heart Surg Forum, 2020, 23(2): E128-E131.
25.	Rupali P, Evangelynn SB, Abraham OC, et al. Granulomatous hepatitis following open heart surgery with cardiopulmonary bypass. Natl Med J India, 2008, 21(5): 222-224.
26.	Kim G, Kim S. Sternal tuberculosis: A case report. J Wound Manag Res, 2019, 15(1): 31-34.
27.	和燕斐, 杨瑞. 胸骨结核CT诊断及临床应用价值. 临床放射学杂志, 2018, 37(10): 1708-1711.
28.	Grover DSB, Rai DV, Grover DH, et al. Imaging diagnosis of sternal tuberculosis- A report of two cases of the ancient disease with a new demeanour. Radiol Case Rep, 2021, 16(10): 3125-3133.
29.	Feki W, Ketata W, Mkaouar N, et al. Isolated sternal tuberculosis in immunocompétent adult. Rev Pneumol Clin, 2018, 74(2): 96-99.
30.	Daniel M, Ricordel C, Lorleac'h A, et al. The illusion of a chest wall tumor: A case-report of sternal tuberculosis. Monaldi Arch Chest Dis, 2022, 92(4): 2144.
31.	Mondoni M, Centola M, Viganò O, et al. Chest pain and a left parasternal soft tissue swelling in an immunocompetent refugee with disseminated tuberculosis. Int J Infect Dis, 2020, 90: 116-118.

1. Parolari G, Sepulcri C, Salsano A, et al. Mycobacterium tuberculosis surgical site infection after cardiac surgery in the COVID-19 era: A case report. Infect Dis Rep, 2022, 14(1): 101-105.
2. Rahlwes KC, Dias BRS, Campos PC, et al. Pathogenicity and virulence of mycobacterium tuberculosis. Virulence, 2023, 14(1): 2150449.
3. Fujiwara T, Yanai H, Hagiya H. Like a shot-through manubrium: A rare presentation of skeletal tuberculosis. Clin Case Rep, 2023, 11(5): e7119.
4. Rizzo V, Salmasi Y, Hunter M, et al. Delayed diagnosis of chronic postoperative sternal infection: A rare case of sternal tuberculosis. BMJ Case Rep, 2018: bcr2017223650.
5. Hamada K, Oishi K, Uehara S, et al. Deep sternal wound tuberculosis with hypo-gamma-globulinemia. Intern Med, 2018, 57(17): 2563-2566.
6. 崔振田, 高永顺, 陆龙. 心脏手术后胸骨感染合并结核杆菌感染11例治疗体会. 中华胸心血管外科杂志, 2018, 34(5): 296-297.
7. Tabaja H, Hajar Z, Kanj SS. A review of eleven cases of tuberculosis presenting as sternal wound abscess after open heart surgery. Infect Dis (Lond), 2017, 49(10): 721-727.
8. Kim HJ, Kim JB, Chung CH. Chronic sternum wound infection caused by mycobacterium tuberculosis after cardiac surgery. Ann Thorac Surg, 2012, 94(4): 1332-1335.
9. Patel P, Tabasi S. Sternal osteomyelitis caused by mycobacterium tuberculosis after open heart surgery. Infect dis clin prac, 2011, 19(5): 359-361.
10. Kestler M, Reves R, Belknap R. Pacemaker wire infection with Mycobacterium tuberculosis: A case report and literature review. Int J Tuberc Lung Dis, 2009, 13(2): 272-274.
11. Wang TK, Wong CF, Au WK, et al. Mycobacterium tuberculosis sternal wound infection after open heart surgery: A case report and review of the literature. Diagn Microbiol Infect Dis, 2007, 58(2): 245-249.
12. Gopal K, Raj A, Rajesh MR, et al. Sternal tuberculosis after sternotomy for coronary artery bypass surgery: A case report and review of the literature. J Thorac Cardiovasc Surg, 2007, 133(5): 1365-1366.
13. Rivas P, Górgolas M, Gimena B, et al. Sternal tuberculosis after open heart surgery. Scand J Infect Dis, 2005, 37(5): 373-374.
14. Achouh P, Aoun N, Hagege A, et al. Mediastinitis due to Mycobacterium tuberculosis after a redo open heart surgery. J Cardiovasc Surg (Torino), 2005, 46(1): 93-94.
15. Sipsas NV, Panayiotakopoulos GD, Zormpala A, et al. Sternal tuberculosis after coronary artery bypass graft surgery. Scand J Infect Dis, 2001, 33(5): 387-388.
16. Aggarwal B, Kamath S, Shatapathy P. Tubercular sternal osteomyelitis and mediastinitis after open heart surgery. Indian Heart J, 1997, 49(3): 313-314.
17. Rubinstien EM, Lehmann T. Sternal osteomyelitis due to mycobacterium tuberculosis following coronary artery bypass surgery. Clin Infect Dis, 1996, 23(1): 202-203.
18. Jauhary T, Hayati F. Unusual sites of tuberculosis mimicking skeletal metastases: A case report. Radiol Case Rep, 2022, 17(6): 2898.
19. Chakaya J, Petersen E, Nantanda R, et al. The WHO Global Tuberculosis 2021 Report - not so good news and turning the tide back to End TB. Int J Infect Dis, 2022, 124 Suppl 1: S26-S29.
20. Bains L, Lal P, Chand T, et al. Isolated primary cold abscess of the sternum: A case report. J Med Case Rep, 2019, 13(1): 267.
21. Yuan SM. Sternal mycobacterial infections. Ann Thorac Med, 2016, 11(2): 103-111.
22. Kabiri EH, Alassane EA, Kamdem MK, et al. Tuberculous cold abscess of the chest wall: A clinical and surgical experience. Report of 16 cases(Case series). Ann Med Surg (Lond), 2020 Feb 13: 51: 54-58.
23. Abe T, Hanawa H, Fujii Y. Gene expression of inflammatory cytokines in major organs by extracorporeal circulation. J Clin Med, 2023, 12(8): 2813.
24. Al-Ebrahim KE. A unique spectrum of tuberculosis flare up related to cardiothoracic surgery. Heart Surg Forum, 2020, 23(2): E128-E131.
25. Rupali P, Evangelynn SB, Abraham OC, et al. Granulomatous hepatitis following open heart surgery with cardiopulmonary bypass. Natl Med J India, 2008, 21(5): 222-224.
26. Kim G, Kim S. Sternal tuberculosis: A case report. J Wound Manag Res, 2019, 15(1): 31-34.
27. 和燕斐, 杨瑞. 胸骨结核CT诊断及临床应用价值. 临床放射学杂志, 2018, 37(10): 1708-1711.
28. Grover DSB, Rai DV, Grover DH, et al. Imaging diagnosis of sternal tuberculosis- A report of two cases of the ancient disease with a new demeanour. Radiol Case Rep, 2021, 16(10): 3125-3133.
29. Feki W, Ketata W, Mkaouar N, et al. Isolated sternal tuberculosis in immunocompétent adult. Rev Pneumol Clin, 2018, 74(2): 96-99.
30. Daniel M, Ricordel C, Lorleac'h A, et al. The illusion of a chest wall tumor: A case-report of sternal tuberculosis. Monaldi Arch Chest Dis, 2022, 92(4): 2144.
31. Mondoni M, Centola M, Viganò O, et al. Chest pain and a left parasternal soft tissue swelling in an immunocompetent refugee with disseminated tuberculosis. Int J Infect Dis, 2020, 90: 116-118.

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