1331665 - Scars on the heart: Petrified myocardium

43 year old male presented with complains of weight loss and fatigue since six months. Further workup was performed with routine blood tests, chest x-ray and CT scan of chest. It revealed dense calcification involving left ventricular myocardium. Patchy parenchymal opacities were seen right lower lobe with multiple parenchymal nodules and pleural effusion. Hematologic work up revealed elevated white blood cell counts and CRP levels. Serum calcium and phosphorus levels were within normal limits. Serum Parathormone and Troponin  levels performed later revealed normal values. There was past history of malaria with prolonged critical illness, mechanical ventilation and prolonged ICU stay. Image guided biopsy of right lung abnormality revealed necrotising inflammation, with high suspicion of tuberculous aetiology.

Diagnostic Techniques and Their Most Important Findings:

The CT scan sections showed dense calcification involving interventricular septum and posterolateral wall. These were observed in linear fashion, encircling LV cavity.  Further workup with MRI was performed for detailed cardiac work up. Left ventricle showed normal morphology and wall motion, with borderline reduction of function (LVEF 47%). Linear areas of altered signal intensities  were observed in interventricular septum and posterolateral wall, at the site of calcification. Focal areas of increased T1 and T2 signals were observed in adjoining myocardium with patchy late gadolinium enhancement. Right ventricle and rest of cardiac structures revealed no significant abnormality. Features were suggestive of long standing indolent myocardial inflammation along with calcification.

Learning Points from this Case:

Calcium deposition in myocardium has been described due to various aetiologies. Dystrophic calcification as sequelae to previous myocardial infarction is the most common cause. Other causes include post-traumatic insult, cardiac surgery, autoimmune diseases, Hyperparathyroidism. The infectious aetiology such as fungal /viral myocarditis and tuberculosis are also listed. Such extensive myocardial calcification is not described in literature with tuberculous involvement. Long term sequelae of previous major illness was considered as differential diagnosis. Patient was started on anti-tuberculous treatment for lung involvement.