Characteristics of sternal <i>Mycobacterium</i> <i>tuberculosis</i> infection after cardiac surgery: A systematic review_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

DOI：

10.7507/1007-4848.202307068

Video：

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Objective To analyze the clinical characteristics of Mycobacterium tuberculosis (Mtb) infection of the sternum after cardiac surgery. Methods A computerized search was conducted in PubMed, Web of Science, Wanfang, and CNKI databases for published case reports of post-cardiac surgery sternal Mtb infections up to July 18, 2023. Two researchers independently screened the included cases, extracted relevant data, and analyzed clinical features. Results A total of 15 articles involving 26 patients were included, comprising 16 males and 10 females, with a mean age of (61.9±15.6) years (range 5-80). Previous surgical histories included coronary artery bypass grafting (14 patients, 53.8%), valve surgery (8 patients, 30.8%), congenital heart disease surgery (3 patients, 11.5%), and aortic surgery (2 patients, 7.7%). The main symptoms and signs were wound abscesses and poor healing, often accompanied by pain, with or without redness and swelling, while systemic symptoms such as low-grade fever, night sweats, and weight loss were typically absent. The median time for infection to be discovered in 13 patients after surgery was 10.0 (3.0, 13.0) months, and the median interval between infection discovery and diagnosis in 9 patients was 3.0 (2.0, 6.0) months. The primary diagnostic methods included Mtb culture, histopathology, and acid-fast staining of debrided bone tissue or pus. One patient died of cardiac arrest before diagnosis. Among the 25 diagnosed patients, 13 received only antitubercular therapy (11 of whom had undergone surgical treatment before diagnosis), while 12 received combined antitubercular and surgical treatment. All 25 patients were successfully cured, with antitubercular therapy lasting 6-12 months. Conclusion Post-cardiac surgery sternal Mtb infection has a prolonged latency period and poses significant diagnostic challenges, leading to high rates of missed and misdiagnosed cases. Timely diagnosis and treatment can markedly improve prognosis.

Citation： WANG Zhihua, HU Junlong, ZHAO Zeyuan, SUN Junjie, LI Zhao, XUAN Jizhong, CHENG Zhaoyun. Characteristics of sternal Mycobacterium tuberculosis infection after cardiac surgery: A systematic review. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(9): 1312-1317. doi: 10.7507/1007-4848.202307068 Copy

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.Cui ZT, Gao YS, Lu L. Experiences of treating sternal infection combined with mycobacterium tuberculosis infection after cardiac surgery. Chin J Thorac Cardiovasc Surg, 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, 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.He YF, Yang R. CT diagnosis of thoracic tuberculosis and its clinical application value. J Clin Radiol, 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.Cui ZT, Gao YS, Lu L. Experiences of treating sternal infection combined with mycobacterium tuberculosis infection after cardiac surgery. Chin J Thorac Cardiovasc Surg, 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, 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.He YF, Yang R. CT diagnosis of thoracic tuberculosis and its clinical application value. J Clin Radiol, 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.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Characteristics of sternal Mycobacterium tuberculosis infection after cardiac surgery: A systematic review

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