key: cord-0028251-8rvm4vgm
authors: Chen, Liyi; Liu, Chong; Liang, Tuo; Ye, Zhen; Huang, Shengsheng; Sun, Xuhua; Yi, Ming; Chen, Tianyou; Li, Hao; Chen, Wuhua; Jiang, Jie; Chen, Jiarui; Guo, Hao; Yao, Yuanlin; Liao, Shian; Yu, Chaojie; Fan, Binguang; Wu, Shaofeng; Zhan, Xinli
title: Pulmonary embolism following the third thoracic tuberculosis surgery: A case report and literature review
date: 2022-01-28
journal: J Clin Lab Anal
DOI: 10.1002/jcla.24256
sha: 8378d133a6947108612fd2ddd8e46c95afe8f9f9
doc_id: 28251
cord_uid: 8rvm4vgm

BACKGROUND: The study aimed to analyze the clinical effects of pulmonary embolism succeeding a third surgery conducted for multiple recurrences in thoracic tuberculosis (TB). CASE REPORT: A 74‐year‐old female patient developed thoracic tuberculosis and was subsequently treated in our hospital in March 2019, October 2020, and February 2021. The third surgical intervention included anterolateral thoracic lesion resection, internal fixation, posterior spinal tuberculous sinus resection, and debridement with suture. The operative time was 172 min resulting in a substantial intraoperative blood loss (2321 ml). Postoperative re‐examination of chest CTPA indicated a strip filling defect and pulmonary embolism in the external branch of the right middle lobe of the lung. After completing the active treatment, the D‐dimer quantification, WBC, CRP, and ESR values were 1261 ng/ml, 7.71 × 10(9)/L, 74.66 mg/L, and 63 mm, respectively. Chest CTPA re‐examination after the treatment showed no signs of pulmonary embolism. CONCLUSION: Patients with a long‐term history of multiple operations, high BMI, cerebral infarction, diabetes, and older age group were more likely to develop pulmonary embolism after spinal tuberculosis surgery. Thus, the possibility of postoperative pulmonary embolism should be thoroughly analyzed before any subsequent surgical treatment in patients with recurrent spinal tuberculosis.

About 10 million people have been estimated to develop TB worldwide, according to the Global Tuberculosis Report, 2020. 1 Spinal TB is the commonly encountered extrapulmonary form of the disease which accounts for nearly 1%-3% of all TB cases. 2 Although spinal TB mostly involves the thoracic vertebrae 3 and usually displays paraspinal abscess formation, intervertebral disk space destruction along with adjacent vertebrae, and neurological impairment. 3, 4 Although the surgical treatment of spinal TB has shown good clinical results, some patients still exhibit TB recurrence leading to subsequent surgical interventions. 5 An earlier study reported that the recurrence rate of spinal TB after the surgery was approximately estimated at 60%. 6 Another study revealed a significant reduction Pulmonary embolism caused by many etiological factors is a disease with a high mortality rate. 8 Although pulmonary embolism is now considered a rare complication of spinal surgery, the obvious risk of pulmonary embolism in such cases is high. 9 At present, pulmonary embolism after spinal TB has been rarely reported in the literature, while the occurrence of pulmonary embolism after multiple spinal TB operations has not been reported to date. This case of pulmonary embolism after the third thoracic TB surgery has been reported for the first time. After the active treatment, the patient's condition improved, and the curative effect was satisfactory. Therefore, this report analyzed the occurrence of pulmonary embolism after succeeding surgical interventions for recurrent spinal TB. 

The physiologic spinal curvature was present, along with no obvious tenderness or pain while percussing each spinous process.

There was an old surgical scar and two sinus passages on the chest and back measuring about 20 cm and 0.5 cm in size, respectively.

Although purulent discharge was observed, obvious inflammation, swelling, and sensory impairment were absent. An assessment of 

The patient underwent surgery on March 5, 2019. After the general anesthesia was given, the patient was placed in the prone position, and the skin was routinely disinfected and covered with sterile towels.

After fully exposing the operating field, the thoracic (T) 7/8 vertebral lesions were completely excised. The bone defects were filled with bone granules and streptomycin powder. Pedicle screws were inserted into the bilateral pedicles of T6-T10, followed by the placement of a cross-connecting device between T7 and T8. After sufficient hemostasis, a drainage tube was placed, followed by the layered suturing.

The patient underwent a second operation on October 21, 2020.

After the application of general anesthesia, the patient was placed in the prone position, while the skin was routinely disinfected and covered with sterile towels. After incising the skin layers, the original internal fixation device was removed. The T5-T8 vertebral lesions 

After the anterolateral approach was completed, the patient was placed in the prone position. After the routine disinfection of the Table 1 ). The patient's vital signs were measured daily ( Figure 11) .

A postoperative CT re-examination showed that the internal fixation device was aligned well (Figure 12 ). The BMI measurement categorized the patient as overweight in all three hospital visits ( Figure 13 ). After the completion of active treatment, chest CTPA reexamination showed no signs of pulmonary embolism ( Figure 14C,D) .

The patient had no other complications and was highly satisfied with the treatment. The patient was again examined and discharged ten days after the surgery. The postoperative radiographs after three months showed that the internal fixation device was in good condition ( Figure 6C ,D).

Osteoarticular TB is a common manifestation of the extrapulmonary form, while spinal TB most commonly occurs after the initia- concern and is frequently prone to recurrence. 13, 14 Early literature reported that the postoperative recurrence rate of spinal tuberculosis was estimated to be 60%. 6 In this case, the patient with spinal TB, after two recurrent episodes, underwent a third surgery in our hospital. This might be related to the fact that superinfection occurred with drug-resistant strains during the treatment. 13, 14 Additionally, the failure of the spinal stability reconstruction device was also a causative factor for the subsequent recurrence. 2, 15 Although several literary insights have displayed the safety profiles and effectiveness of using internal fixation devices for treating TB, 16, 17 few other studies demonstrated that bacterial presence could generate a biofilm matrix consisting of proteins and polysaccharides on the surface of implanted materials, which might cause re-infection. 18 The patient reported to our department three times, and the BMI measurement in each hospitalization visit showed an excessive measure of obesity ( Figure 13 ). Multivariate analysis of the recent literature revealed that independent risk factors for pulmonary embolism included total operative time and BMI. 19 Obese people had twice the risk of developing postoperative pulmonary embolism. 20 This might be due to the fact that increased BMI and obesity usually prolong the operating time, which could easily lead to postoperative complications. 21 In this case report, the BMI of the patient in all three hospitalization visits was over 26, while the BMI in the third hospitalization was as high as 26.14, thus implying that this might be a high-risk factor for initiating pulmonary embolism following spinal TB surgery.

The reported patient had a three-year history of stroke. Although the patients did not have a significant sequel of stroke, their behavior was significantly altered when compared with those without this disease. This might be due to decreased mobility after stroke and increased susceptibility to deep vein thrombosis, which is a potential side effect of pulmonary embolism. 22 Pulmonary embolism after a stroke has been frequently reported due to an association of the stroke mechanism with hypercoagulability in vivo. 23 Thus, it was easily speculated that pulmonary embolism was also closely related to hypercoagulability. 24 It has been indicated that the process of the diabetic patients undergoing Charcot foot reconstruction was complicated by the pulmonary embolism initiation. 25 This was in accordance with our result reporting a pulmonary embolism after the surgical treatment.

It has also been reported that the incidence of pulmonary embolism was particularly high in type 2 diabetes patients. 26 The underlying mechanism in such cases might be the innate activation of hyperglycemia that leads to abnormal coagulation and impaired fibrinolysis and thus increasing the risk of thrombosis. 27, 28 This case report presented a 74-year-old female patient with postoperative pulmonary embolism. The elderly population is more susceptible to pulmonary embolism after the surgical treatment than the younger age group. 29 It was also evident that the mortality rates increased with the advancing age. 30 A study by Zhou et al. showed that hypertensive patients older than 60 years were more prone to pulmonary embolism, 31 which might be attributable to the hypercoagulable state of elder patients with hypertension. 32 The patient in this case report was 74 years old and had a slightly higher blood pressure during the entire hospitalization, which was consistent with the results of previous studies. 29 nal cord injury has been reported to range from 14.3% to 33.3%, [34] [35] [36] stating that the occurrence of deep vein thrombosis was an important risk factor for pulmonary embolism. In this case report, the recurrence of TB abscess after spinal TB surgery caused spinal cord injury and deep vein thrombosis, which might have initiated pulmonary embolism.

After active anticoagulation and anti-infection treatment, the clinical effect of the patient was satisfactory, and no thrombosis was found in the lung CTPA re-examination. Throughout the hospitalization, the patient's routine blood tests indicated a gradual improvement in her condition (Figures 9 and 10 , Table 1 ). The patient's vital signs were stable ( Figure 11 ). Anticoagulant therapy is extremely important in such patients with pulmonary embolism, and its efficacy does not significantly differ from thrombolytic therapy. 37 Since the patients with pulmonary embolism were given timely and effective anticoagulant therapy, the exercise capacity and ventilatory efficiency improved significantly, and the clinical treatment outcome was satisfactory. 38 This was in accordance with the treatment strategy and clinical effect reported in our case. 

Not applicable.

All authors declare no conflicts of interest.

Ly C wrote the article and prepared Figures 1-14 and Table 1 . C L contributed equally to this work and should be considered cofirst authors. All authors reviewed the article and have read and approved the study.

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

The original contributions presented in the study are included in the article/supplementary material, and further inquiries can be di- 

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