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Endocardial Tuberculosis

2014; Elsevier BV; Volume: 98; Issue: 4 Linguagem: Inglês

10.1016/j.athoracsur.2014.06.091

1552-6259

Pranav Subbaraya Kandachar, Devajyoti Guin, Suravi Mohanty, Namita Sinha, Mary G. George, Savitha Nagaraj, Saba Fathima, Navin Lal,

Cardiac tumors and thrombi

We report a 30-year-old male patient with persistent fever, history of stroke, and a left atrial mass. He was diagnosed as miliary pulmonary tuberculosis radiologically and had fever despite 2 months of antitubercular treatment. The mass was excised and fever resolved. Acid fast bacilli (AFB) were demonstrable on Ziehl Neelsen stain and routine histopathology. To the best of our knowledge, the visualization of AFB from an intracardiac lesion on ZN staining has not been reported earlier and tuberculosis must be considered in the differential diagnosis of left atrial masses. We report a 30-year-old male patient with persistent fever, history of stroke, and a left atrial mass. He was diagnosed as miliary pulmonary tuberculosis radiologically and had fever despite 2 months of antitubercular treatment. The mass was excised and fever resolved. Acid fast bacilli (AFB) were demonstrable on Ziehl Neelsen stain and routine histopathology. To the best of our knowledge, the visualization of AFB from an intracardiac lesion on ZN staining has not been reported earlier and tuberculosis must be considered in the differential diagnosis of left atrial masses. Tuberculosis is the second greatest killer worldwide due to a single infectious agent after human immunodeficiency virus. Pulmonary tuberculosis (TB) accounts for up to 85% of all cases. Extrapulmonary TB usually occurs in lymph nodes, abdomen, bony skeleton, and the central nervous system. Heart, thyroid, pancreas, and skeletal muscle were thought to be unaffected. Cardiac involvement in TB accounts for 0.5% of extrapulmonary TB [1Rodriquez E. Soler R. Juffé A. Salqado L. CT and MR findings in a calcified myocardial tuberculoma of the left ventricle.J Comput Assist Tomogr. 2001; 25: 577-579Crossref PubMed Scopus (29) Google Scholar].Here we present a case of a 30-year-old male with suspected sputum negative, radiologically diagnosed pulmonary miliary tuberculosis with persisting fever spikes despite 2 months of antitubercular treatment. During investigations, echocardiography (Fig 1) revealed a pedunculated mass in the left atrium. Computed tomography (CT) of the thorax showed miliary nodules in lungs and a 16 × 9 × 8 mm-sized heterogeneously enhancing subtle lesion in the left atrium adjacent to a mitral valve myxoma or tubercular granuloma (Fig 2). He had a history of left hemiplegia 2 months ago that had resolved completely over a few hours. Computed tomography of the brain showed a small, nonhemorrhagic infarct in the left thalamic region. The left atrial mass was excised under cardiopulmonary bypass with cardioplegic arrest. The mass was about 1.5 cm × 0.5 cm and was attached to the roof of the left atrium by a slender stalk. On ZN stain (Fig 3) and histopathologic examination (Fig 4), multiple acid fast bacilli were found within this mass. The fever resolved over the next 2 weeks postoperatively.Fig 2Computed tomography (CT) of thorax (reconstructed lateral view) showing a 16 × 9 × 8 mm heterogeneously enhancing subtle lesion in the left atrium adjacent to the mitral valve (white arrow). Inset: CT of thorax also showing miliary tubercles in the lung fields (black arrow).View Large Image Figure ViewerDownload (PPT)Fig 3Ziehl Neelsen stain (oil immersion ×1,000) from the mass showing acid fast bacilli (black arrows).View Large Image Figure ViewerDownload (PPT)Fig 4Histopathologic examination of endocardium (hematoxylin and eosin stain, ×400) showing granuloma (black arrows).View Large Image Figure ViewerDownload (PPT)CommentCardiovascular TB has been reported as early as 1761 by Giovanni Battista Morgagni and generally involves the pericardium. Myocardial TB may occur due to hematogenous spread, lymphatic spread from mediastinal lymph nodes, or direct involvement from pericardium [2Crocco J.A. Cardiovascular tuberculosis.in: Schlossberg D. Tuberculosis. 3rd ed. Springer-Verlag, New York1994: 179-187Crossref Google Scholar].Endocardial involvement by TB is extremely rare, with only a few live reported cases to date [3Sultan F.A. Fatimi S. Jamil B. Moustafa S.E. Mookadam F. Tuberculous endocarditis: valvular and right atrial involvement.Eur J Echocardiogr. 2010; 11: E13Crossref PubMed Scopus (15) Google Scholar, 4Klingler K. Brändli O. Doerfler M. Schluger N. Rom W.N. Valvular endocarditis due to Mycobacterium tuberculosis.Int J Tuberc Lung Dis. 1998; 2: 435-437PubMed Google Scholar, 5Sogabe O. Ohya T. A case of tuberculous endocarditis with acute aortic valve insufficiency and annular subvalvular left ventricular aneurysm.Gen Thorac Cardiovasc Surg. 2007; 55: 61-64Crossref PubMed Scopus (14) Google Scholar]. There are few reports of tubercular valvular endocarditis and of the 3 live patients reported, 2 were diagnosed on typical histopathologic appearances and 1 was diagnosed by positive culture of the excised valve [6Cantinotti M. De Gaudio M. de Martino M. et al.Intracardiac left atrial tuberculoma in an eleven month-old infant: case report.BMC Infect Dis. 2011; 11: 359Crossref PubMed Scopus (15) Google Scholar, 7Rao V.R. Jagannath K. Sunil P.K. Madhusudana N. A rare disappearing right atrial mass.Interact Cardiovasc Thorac Surg. 2012; 15: 290-291Crossref PubMed Scopus (8) Google Scholar, 8Sarma S. Kumar N. Sharma S. Unusual presentation of a culture-positive right atrial mass.J Cardiovasc Dis Res. 2013; 4: 68-70Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. However, actual visualization of AFB in an intracardiac lesion has not been reported so far and tubercular vegetation must be considered in the differential diagnosis of left atrial masses.Conventionally, surgery is indicated when there is hemodynamic instability, refractory arrhythmia, or life threatening impending embolism. In the absence of these, the role of surgery is not well defined; however, in cases where diagnosis remains questionable, surgical intervention should probably be considered. Tuberculosis is the second greatest killer worldwide due to a single infectious agent after human immunodeficiency virus. Pulmonary tuberculosis (TB) accounts for up to 85% of all cases. Extrapulmonary TB usually occurs in lymph nodes, abdomen, bony skeleton, and the central nervous system. Heart, thyroid, pancreas, and skeletal muscle were thought to be unaffected. Cardiac involvement in TB accounts for 0.5% of extrapulmonary TB [1Rodriquez E. Soler R. Juffé A. Salqado L. CT and MR findings in a calcified myocardial tuberculoma of the left ventricle.J Comput Assist Tomogr. 2001; 25: 577-579Crossref PubMed Scopus (29) Google Scholar]. Here we present a case of a 30-year-old male with suspected sputum negative, radiologically diagnosed pulmonary miliary tuberculosis with persisting fever spikes despite 2 months of antitubercular treatment. During investigations, echocardiography (Fig 1) revealed a pedunculated mass in the left atrium. Computed tomography (CT) of the thorax showed miliary nodules in lungs and a 16 × 9 × 8 mm-sized heterogeneously enhancing subtle lesion in the left atrium adjacent to a mitral valve myxoma or tubercular granuloma (Fig 2). He had a history of left hemiplegia 2 months ago that had resolved completely over a few hours. Computed tomography of the brain showed a small, nonhemorrhagic infarct in the left thalamic region. The left atrial mass was excised under cardiopulmonary bypass with cardioplegic arrest. The mass was about 1.5 cm × 0.5 cm and was attached to the roof of the left atrium by a slender stalk. On ZN stain (Fig 3) and histopathologic examination (Fig 4), multiple acid fast bacilli were found within this mass. The fever resolved over the next 2 weeks postoperatively. CommentCardiovascular TB has been reported as early as 1761 by Giovanni Battista Morgagni and generally involves the pericardium. Myocardial TB may occur due to hematogenous spread, lymphatic spread from mediastinal lymph nodes, or direct involvement from pericardium [2Crocco J.A. Cardiovascular tuberculosis.in: Schlossberg D. Tuberculosis. 3rd ed. Springer-Verlag, New York1994: 179-187Crossref Google Scholar].Endocardial involvement by TB is extremely rare, with only a few live reported cases to date [3Sultan F.A. Fatimi S. Jamil B. Moustafa S.E. Mookadam F. Tuberculous endocarditis: valvular and right atrial involvement.Eur J Echocardiogr. 2010; 11: E13Crossref PubMed Scopus (15) Google Scholar, 4Klingler K. Brändli O. Doerfler M. Schluger N. Rom W.N. Valvular endocarditis due to Mycobacterium tuberculosis.Int J Tuberc Lung Dis. 1998; 2: 435-437PubMed Google Scholar, 5Sogabe O. Ohya T. A case of tuberculous endocarditis with acute aortic valve insufficiency and annular subvalvular left ventricular aneurysm.Gen Thorac Cardiovasc Surg. 2007; 55: 61-64Crossref PubMed Scopus (14) Google Scholar]. There are few reports of tubercular valvular endocarditis and of the 3 live patients reported, 2 were diagnosed on typical histopathologic appearances and 1 was diagnosed by positive culture of the excised valve [6Cantinotti M. De Gaudio M. de Martino M. et al.Intracardiac left atrial tuberculoma in an eleven month-old infant: case report.BMC Infect Dis. 2011; 11: 359Crossref PubMed Scopus (15) Google Scholar, 7Rao V.R. Jagannath K. Sunil P.K. Madhusudana N. A rare disappearing right atrial mass.Interact Cardiovasc Thorac Surg. 2012; 15: 290-291Crossref PubMed Scopus (8) Google Scholar, 8Sarma S. Kumar N. Sharma S. Unusual presentation of a culture-positive right atrial mass.J Cardiovasc Dis Res. 2013; 4: 68-70Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. However, actual visualization of AFB in an intracardiac lesion has not been reported so far and tubercular vegetation must be considered in the differential diagnosis of left atrial masses.Conventionally, surgery is indicated when there is hemodynamic instability, refractory arrhythmia, or life threatening impending embolism. In the absence of these, the role of surgery is not well defined; however, in cases where diagnosis remains questionable, surgical intervention should probably be considered. Cardiovascular TB has been reported as early as 1761 by Giovanni Battista Morgagni and generally involves the pericardium. Myocardial TB may occur due to hematogenous spread, lymphatic spread from mediastinal lymph nodes, or direct involvement from pericardium [2Crocco J.A. Cardiovascular tuberculosis.in: Schlossberg D. Tuberculosis. 3rd ed. Springer-Verlag, New York1994: 179-187Crossref Google Scholar]. Endocardial involvement by TB is extremely rare, with only a few live reported cases to date [3Sultan F.A. Fatimi S. Jamil B. Moustafa S.E. Mookadam F. Tuberculous endocarditis: valvular and right atrial involvement.Eur J Echocardiogr. 2010; 11: E13Crossref PubMed Scopus (15) Google Scholar, 4Klingler K. Brändli O. Doerfler M. Schluger N. Rom W.N. Valvular endocarditis due to Mycobacterium tuberculosis.Int J Tuberc Lung Dis. 1998; 2: 435-437PubMed Google Scholar, 5Sogabe O. Ohya T. A case of tuberculous endocarditis with acute aortic valve insufficiency and annular subvalvular left ventricular aneurysm.Gen Thorac Cardiovasc Surg. 2007; 55: 61-64Crossref PubMed Scopus (14) Google Scholar]. There are few reports of tubercular valvular endocarditis and of the 3 live patients reported, 2 were diagnosed on typical histopathologic appearances and 1 was diagnosed by positive culture of the excised valve [6Cantinotti M. De Gaudio M. de Martino M. et al.Intracardiac left atrial tuberculoma in an eleven month-old infant: case report.BMC Infect Dis. 2011; 11: 359Crossref PubMed Scopus (15) Google Scholar, 7Rao V.R. Jagannath K. Sunil P.K. Madhusudana N. A rare disappearing right atrial mass.Interact Cardiovasc Thorac Surg. 2012; 15: 290-291Crossref PubMed Scopus (8) Google Scholar, 8Sarma S. Kumar N. Sharma S. Unusual presentation of a culture-positive right atrial mass.J Cardiovasc Dis Res. 2013; 4: 68-70Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. However, actual visualization of AFB in an intracardiac lesion has not been reported so far and tubercular vegetation must be considered in the differential diagnosis of left atrial masses. Conventionally, surgery is indicated when there is hemodynamic instability, refractory arrhythmia, or life threatening impending embolism. In the absence of these, the role of surgery is not well defined; however, in cases where diagnosis remains questionable, surgical intervention should probably be considered.