1336077 - Tumor or Tuberculosis?: Time solved the mystery.

Description of Clinical Presentation: 28 year old young male presented with breathlessness and generalized fatigue. Chest X-ray revealed right basal pleural effusion. Pleural fluid cytology was suggestive of tuberculosis and hence anti-tuberculous treatment was started. However, he did not tolerate few first line medications (Rifampicin) and continued to have cough, weakness and chest wall swelling. Contrast CT scan chest was performed, which revealed few mediastinal lymphnodes and rib erosions. There was soft tissue attenuating infiltrating lesion along free wall of right atrium and ventricle. It showed smooth margins and homogenous post contrast enhancement. No pericardial effusion was observed.

Diagnostic Techniques and Their Most Important Findings:

In view of intracardiac abnormality, cardiac MRI was performed for detailed work up. There was smooth homogenous signal intensity mass lesion along free wall of right atrium and ventricle. It showed vascularity on first pass perfusion images with intense enhancement on delayed images. There was also thickening of interatrial septum. Left ventricle revealed normal morphology and function. No regional wall motion abnormality or late gadolinium enhancement was seen.

 

Learning Points from this Case:

Isolated right ventricular involvement with atypical imaging features was unusual for this case. Also, patient developed these abnormalities in spite of anti-tuberculous therapy. Differentials of primary cardiac lymphoma or other malignancy were considered and hence endomyocardial biopsy was recommended.

 

However, patient refused for invasive procedure and continued same medical treatment.

Follow up visit after 6 months revealed improvement in clinical symptoms. There was also partial regression of right heart abnormality.

 

Tuberculosis in endemic countries can have different presentations and is a great masquerader. Cardiovascular involvement is rare, but can cause serious and life threatening complications. High clinical suspicion with increasing recognition of entity helps to detect this ‘curable’ ; form of cardiomyopathy.