SEORANG PENDERITA COR

PULMONALE et CAUSA
SINDROMA OBSTRUKTIF
PASCA TUBERCULOSIS (SOPT)
PARU

Brinna Anindita
Novira Widajanti

Department of Internal Medicine

Medical Faculty of Airlangga University
Dr Soetomo Teaching Hospital
Surabaya
2017
Background
Dyspnea is a commonly disturbing complaint and is
one of the most common reasons for seeking medical
help.

The etiology of dyspnea may be multifactorial, the heart

and lung etiology dominates the cause of dyspnea.

(Wahls, 2012)
 Cor Pulmonale
Heart failure is a clinical syndrome characterized by
shortness of breath and fatigue (at rest or during
activity) caused by structural abnormalities or heart
function.

Cor pulmonale is a hypertrophy or right ventricular

dilatation due to pulmonary hypertension caused by a
disease that attacks the structure, lung function, or
pulmonary vessels that may progress to right heart
failure.

(Panggabean, 2015)
 Tuberculosis
The mechanism of pulmonary hypertension in patients
with pulmonary tuberculosis in treatment is thought to
originate from damage to pulmonary residue structures
and lung function abnormalities that cause gas
exchange disorders resulting in chronic hypoxia.

(Ahmed E, Ibrahim A, Elshafie S ,2011)

 Case Report
Identity :
Name : Tn. H
Sex : Male
Age : 34 th
Address : Bangkalan,
Madura
Occupation : unemployed
 History
Chief Complain:
Shortness of breath

Present Illness :
Fluctuating shortness of breath since 1 year before
admission especially during activity, sometimes
accompanied by cough. Patient felt more comfortable
sleeping with two pillows. Patient also complained of
palpitation since 1 month PTA.
 Fever, night sweats, and weight loss are denied
Swelling in both limbs 2 months PTA
Swelling in scrotum 2 weeks PTA
Patients with a history of pulmonary tuberculosis 1,5 years
ago and went to Puskesmas Karangtembok for 8 months
then the patient stopped the treatment because he felt he
had improved.

Since knowing that the patient was infected with

Tuberculosis, the patient stopped working
 Physical Examination
anemia (-)
ict (-)/ cyan (+) /dysp
(+), JVP

Variation of heart
sound +, widened heart
GCS 456, weak
side , decreased breath
sound on left
Vital Sign:
hemithorax
BP 100/60 mmHg
Pulse 50 bpm, irregular
Resp rate 28 tpm Minimal ascites (+),
Axillary temp 37,20 C swollen scrotum

swollen both lower

extremity
 Laboratory Finding
BGA
Hb 13.30 g/dL pH 7,42
Leukocyte 8.800 pCO2 77
Netrofil 74,6% pO2 97
Trombocyte 234.000 HCO3 49,9
SGOT/PT 23/16 Beecf 25,4
GDA 130 SO2 98%
BUN 15 AaDO2 42
SK 1,47
Albumin 3,9
Na 134
K 3,8
Cl 83
 Supportive Examination
Electrocardiogram : irama
fibrilasi atrial dengan respon
ventrikel lambat dan ultiple
PVC
 Chest X-ray :
cor : left heart boundary
closed by cloaking; the
pulmo appears to be
fibroetracted in the left
suprahiler, fibroinfiltrates with
multiple cavities in the right
suprahiler and multiple
calcifications in the right lung
field. Appeared left-right
pleural thickening.
Impression: Pulmonary TB
with bilateral schwarte
 Usg Abdomen : didapatkan asites minimal dan curiga congestive liver.

Echocardiography :

Katup : MR trivial, TR sedang (TR max PG 70,16), PR sedang (PR desclope 2,2 m/s)

Dimensi ruang ruang jantung : LA/ LV normal, RA dilatasi dnegan est RAP 15 mmHg, RV
dilatasi dengan pulmonal hipertensi berat dengan PASP 85,16 mmHg

Fungsi sistolik LV normal (EF 75 %)

Fungsi diastolic LV normal

Fungsi sistolik RV normal

Analisa segmental LV normokinetik

Tidak didapatkan LVH

 Consultation with cardiology department : Currently we
have cyanosis which can be caused by: (1) old
pulmonary TB that causes cor pulmonale, (2) cyanotic
heart disease

Consultation with pulmonology department: Currently

we assessed patient with inactive chronic lung TB
Assesment
Cor pulmonale et causa chronic airflow obstruction
pulmonary TB + atrial fibrilasi slow responsed ventricle +
AKI

Planning
genexpert, k/s sputum M. Tuberculosis, smear gram,
Echocardiography, cek anti HCV, Calsium, Phosphat,
Magnesium, uric acid

Therapy
Diet HCLP 1900 kkal/day, fluid balance, tampung produksi urine, minum
maksimal 500 cc dalam 24 jam, inj. Furosemide 3 x 20 mg, po
spironolactone 25 mg 0 - 0, Dorner 3 x 1 tablet.
 Progression Notes :
2nd and 3rd day:
patients still complain of tightness, palpitating began to improve,
swelling on the scrotum and both limbs. Planning diagnosis:
laboratory evaluation 3 days post-therapy.
Result :
Hb 13,19
Wbc 7450
Neutrofil 73,21
Plt 177.900
As.urat 16,10
fosfat 4,6
Mg 2,3
Ca 8,2
Anti HCV Non reaktif
4th day
S : dyspnea decreased, swollen of the scrotum and both limb began to decreased
O :BP : 100/60 mmHg ;Pulse 64 bpm;Resp rate 20 tpm; Axillary temp 370
A :Cor pulmonale et causa SOPT + AKI+ atrial fibrilasi slow respond ventricle+
congestive liver
PDx : echocardiography sisipan, kultur sensitifitas M. Tuberculosis dan smear
BTA
Planning Tx:i diet HCLPLS 1900 kkal/day protein 0,6 gr/ KgBB/ dau, fIuid balance
= O + 500cc, inf. D5 7 tpm, tampung produksi urine, minum maksimal 500 cc
dalam 24 jam, inj. Furosemide 3 x 20 mg, po spironolactone 25 mg 0 - 0,
Dorner 3 x 1 tablet, allopurinol 100 mg 1 x 1, nebul combivent 1 ampul setiap 6
jam
5th day
On the fifth day of treatment we re-examined renal function and liver
function with SGOT result: 21 SGPT 17, BUN: 35 SK: 1,3 to rule out the
diagnosis of chronic renal failure and congestive live

Hasil echocardiography sisipan didapatkan:

Katup katup : MR trivial,
Assesment : corTRpulmonal
sedang (TR max PG
et cause 67,37), AR ringan (AR
sindroma
Sdesclopeobstruktif
0,9 m/s, AR PHTtuberkulosis
pasca 527 ms) + cardiorenal syndrome
type 1 +ruang
Dimensi ruang atrialjantung : LA/
fibrilasi LV normal
respon (LA mayor
ventrikel lambat5,1
+ cm, LA minor
2,8 cm) ; Small LV (LVIDd
congestive liver.3,1 cm) RA dilatasi (RA mayor 5,5 cm, RA minor
4,8 cm dengan est RAP 15 mmHg, RV dilatasi dengan pulmonal hipertensi
berat dengan PASP 82,37 mmHg. Tidak tampak thrombus/ vegetasi
intrakardiak.
Fungsi sistolik LV normal (EF 76 %)
Fungsi diastolic LV normal
Fungsi sistolik RV menurun
Analisa segmental LV normokinetik
Tidak didapatkan LVH
 6th day
On the sixth day of treatment, dyspnea diminished, the swelling on both limbs and
scrotum reduced, patient still complained palpitated. Appetite within normal limit.
Patient discharged and scheduled for routine visit to Cardiology, pulmonology and
internal medicine out patient clinic, with furosemide tablet 40 mg 1-1-1 ,
spironolactone tablet 100 mg 1-0-0, dorner tablet 20 mg 3x1, dan allopurinol
tablet 100 mg 0-0-1 need to be consumed.
DISCUSSION
 Dyspnea
Dyspne is a subjective experience of a discomfort in
breathing, a symptom that is generally a result of increased
effort in inspiration and expiration .
Pasien yang datang dengan keluhan sesak harus dilakukan
anamnesis mengenai keluhan saat ini dan riwayat penyakit
dahulu serta pemeriksaan fisik dan bila perlu dilakukan
pemeriksaan penunjang untuk menyingkirkan etiologi sesak
yang dapat berasal dari sistem kardiovaskular, sistem
pernafasan ataupun sistem filtrasi dan ekskresi dalam hal ini
organ ginjal secara khusus.
(Longo, et all , 2013)
( Longo, et all, 2013)
 On this patient :
Patient complained of shortness of breath that
fluctuating since 1 year ago, tightness especially felt
during the sometimes accompanied by cough,
improved with rest. Patient felt more comfortable
when sleeping with 2 pillows. Patients complained of
frequent pounding since approximately 1 month PTA,
chest pain is refuted. Fever, night sweats, and weight
loss are denied by the patient. Patients also
complained of swelling in both limbs since 2 months
of PTA, swelling felt heavy since 2 weeks PTA
accompanied by a swollen scrotum. Based on
anamnesis, physical examination, and investigation,
the patient is diagnosed with cor pulmonale et cause
obstructive syndrome post tuberculosis + atrial
fibrillation
 Heart Failure

Acute Chronic With reduced With preserved

Ejection Ejection
Fraction Fraction
(HRrEF) (HRpEF)

Left Right

(Ali Ghanie, papdi, 2009) (AHA guidelines, 2017). .

 Cor Pulmonale
Changes in the structure or function of the right
ventricle caused by pulmonary hypertension which is a
result from diseases that affected the lungs or
pulmonary blood vessel.

(Harun S, Prasetya I, 2009)

 Etiology
Pulmonary vascular disease;
Blood pressure in the pulmonary artery by a mediastinal
Patients were diagnosed with pulmonary tuberculosis
tumor, aneurysm, granuloma, or fibrosis;
1,5 years ago and went to Karangtembok primaru
health care for taking anti TB drugs for 8 months, then
Neurovascular and chest wall diseases;
the patient stopped the treatment because he felt he
had improved. Since knowing that the patient is
Diseases affecting pulmonary airflow, alveoli, including
infected with Tuberculosis, the patient stops working
chronic obstrictive pulmonary disease (COPD).
Other lung diseases are interstitial lung disease and
breathing disorders during sleep

(Harun S, Prasetya I, 2009)

 Pulmonal Hypertension
Caused by diseases affecting the structure and / or
function of the lungs can cause right ventricular
enlargement (hypertrophy and / or dilation) and may
cause right heart failure
Bilateral and extensive tuberculosis may cause
pulmonary hypertension because of extensive fibrosis
that causes pulmonary parenchymal damage

(Weitzblum,2003 ; Devi, 2012)

 Pulmonal Hypertension
The prevalence of cor pulmonale in pulmonary tuberculosis
patients was 11%
Increased jugular venous pressure, liver enlargement and
Result
lower of patients
extremity Echocardiography: RV dilatasi
edema.
dengan pulmonal hipertensi berat dengan PASP 85,16
ThemmHg
majority of patients have pulmonary hypertension as
evidenced by right ventricular hypertrophy
Dilatation of RA / RV RVSP> 40 mmHg , paradox IVS
movement IV TAPSE <16 mm dengan epigastric beat(92%),
loud P(70%) dan palpable P (52% )

(N Kotresh, Raghavendra, Jaligidad K, 2016 )

 Sindroma Obstruktif Pasca
Tuberculosis (SOPT)
Unclear pathogenesis
The most common post-TB recurrent symptom is a
lung impairment disorder with an obstructive disorder
that has clinical features similar to Chronic Obstructive
Pulmonary Disease (COPD)
Patients with a history of TB treatment 1.5 years ago
and currently complaints of shortness and signs of
oxygen demand. From the results of consultations
with pulmonology department concluded in the chest
x ray appears broad fibrotic images on hemithorax
dextra, and the presence of multiple cavities in both
hemithorax thorax images can be a picture of former
pulmonary TB
 Treatment
Oxygen
Digitalis
DiureticVasodilator
Anticoagulant

On this Patient : Diet HCLP 1900 kkal/day, fluid

balance, tampung produksi urine, minum maksimal
500 cc dalam 24 jam, inj. Furosemide 3 x 20 mg, po
spironolactone 25 mg 0 - 0, Dorner 3 x 1 tablet and
for ambulatoir treatment furosemide tablet 40 mg 1-1-
1 , spironolactone tablet 100 mg 1-0-0, dorner tablet
20 mg 3x1, dan allopurinol tablet 100 mg 0-0-1
 Prognosis
In a recent study of 100 cases of pulmonary tuberculosis, 10 cases (10%) had clinical
evidence of cor pulmonale with right heart involvement.

The incidence of cor pulmonale is lower in patients less than 40 years old with
pulmonary tuberculosis

Patients with peripheral edema have a five year survival rat of only about 30 percent

(N Kotresh, Raghavendra, Jaligidad Kadappa ,2016) ; (Bhattacharya ,2004)

 Ringkasan
There have been reported a case of a cor pulmonale
resulting from post-tuberculosis obstructive syndrome.
Cor pulmonale is closely associated with pulmonary
hypertension. The diagnosis of cor pulmonale can be
established if there is evidence of pulmonary
hypertension due to pulmonary function and or lung
function. Investigations that can be performed to
support the diagnosis of cor pulmonal include
laboratory examination, chest X-ray examination,
echocardiography, CT scan, and EKG examination
Terima Kasih