Ann Thorac Surg 1995;60:181-182
© 1995 The Society of Thoracic Surgeons
Case Reports
Submitral Left Ventricular Tuberculoma
Rufus Baretti, MD,
Lothar Eckel, MD,
Friedhelm Beyersdorf, MD
Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
Accepted for publication November 7, 1994.
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Abstract
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A 62-year-old woman suffered from increasing dyspnea and an impaired general condition. Chest roentgenograms and echocardiogram showed a dense mass at the left atrioventricular junction resulting in the preoperative working diagnosis of a myocardial myxoma. Intraoperatively, an isolated tuberculoma was found caudal to the posterior leaflet of the mitral valve. This case report describes the successful surgical and postoperative medical treatment of an isolated myocardial tuberculoma.
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Introduction
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A 62-year-old woman had an operative resection of an abscess in the lateral neck region at 36 years of age. Histologic determination did not exclude a tuberculous infection. Suffering from chronic bronchitis for the past 2 years, she had taken two types of medication: an oral theophylline and inhaled ß-sympathomimetic. The patient's condition began declining 8 weeks before admission. Physical examination was negative except for a grade 2 systolic murmur over the right upper sternal border. The patient had a normal body temperature and displayed no symptoms of infection or coronary artery disease. Blood counts, erythrocyte sedimentation rate, and routine serum chemistry were negative. The electrocardiogram showed a normal sinus rhythm. Chest roentgenograms disclosed a calcified mass, 2x3 cm in size, at the myocardial ventricles involving the atrioventricular junction. An echocardiogram showed a good contractility of both ventricles and normal aortic valve function, but also mitral regurgitation. At the posterior leaflet of the mitral valve an echodense shadow, 2x3 cm, was noted. Localization and size of the tumor, character, and acute onset of clinical symptoms led us to offer the working diagnosis of a myocardial myxoma. This led to the indication for operative resection.
The patient was placed on cardiopulmonary bypass. After median sternotomy and incision in the left atrium, a small mitral incompetence was obvious. Usually, a ``smiling'' mitral valve with a concave and convex edge of the posterior and anterior leaflet, respectively, is expected. This normal configuration had been altered to a ``nonsmiling'' mitral valve (Fig 1
) because the tumor in the left ventricular wall caudal to the atrioventricular junction protruded against the posterior leaflet. This resulted in a convex and concave edge of the posterior and anterior leaflet, respectively, and a gap between the leaflets. Caudal to the annulus of the valve, the rear side of the posterior leaflet was completely adherent to the tumor, which limited mobility. This simultaneously resulted in both a partial obstruction of the left atrial outflow tract and in mitral incompetence. After making a crosswise, 2.5-cm-long incision on the posterior leaflet and cutting off the adhesions, a prominent capsule, 2x3 cm in size, became apparent in the left ventricular wall. The capsule was incised and a pasty white-yellowish mass containing grains was removed. Thereafter the complete intramural capsule was resected from the left ventricular wall. The incision of the posterior leaflet was fixed again by single stitches. During beating heart condition, a transesophageal echocardiogram intraoperatively showed minimal mitral regurgitation. Myocardial contractility was excellent and the submitral filling defect had become smaller. After the chest was closed, the patient was hemodynamically stable without drug support. The postoperative course was uncomplicated.
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Fig 1. . Exposure of the mitral valve after median sternotomy and opening of the left atrium from the right side. Note the ``nonsmiling'' mitral valve with protubation of the posterior leaflet.
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Histologic examination of the pasty mass from the capsule showed a white-yellowish amorphous substance containing chalky bodies. A biopsy specimen taken from a mediastinal lymphnode disclosed many proliferating macrophages and anthracotic pigment like that found in chronic lymphadenitis. Ziel-Neelsen coloring did not detect any acid-fast bacilli in the myocardial tumor, nor in the mediastinal lymphnode biopsy. Microbiotic cultures from the biopsies, aspirated stomach juice, repetitive blood samples, and nose swabs were negative for pathogens. The polymerase chain reaction of the myocardial resection material identified the gene of Mycobacterium tuberculosis.
Despite the negative results for detection of pathogens during early postoperative course, application of antitubercular therapy was started because of suspicion of an opened tuberculoma with hematogenous systemically spreading infectious material. The therapy was conducted with ethambutol, 400 mg 3 times per day; rifampicine, 600 mg once a day; and isoniazid, 300 mg once a day. After the operation, white blood cell counts increased to 30,000/mL but decreased on the fifth postoperative day to 12,000/mL and remained stable in this range until discharge on the tenth postoperative day. Three months after the operation, the patient's condition had improved and she displayed no symptoms of infection.
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Comment
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After introduction of antituberculous chemotherapy, myocardial tuberculosis was reported to comprise less than 0.1% of tuberculous infections [1]. After decades of decline, the incidence of tuberculosis in the United States began to increase in 1986 [2], and is expected to increase substantially worldwide during the next 10 years [3]. Thus, we may expect also an increasing number of patients with myocardial tuberculosis. There are three distinct types of myocardial tuberculosis: nodular tuberculomas in different sizes with central caseating, formed by confluent foci of tuberculous infection; miliary tuberculosis due to blood-spread infection; and diffuse infiltration with giant cells and lymphocytes starting from a tuberculous pericarditis. The miliary tuberculosis is the most frequent. Most reports describe tuberculous pericarditis resulting in involvement of the epicardium, tamponade, or cardial constriction [4, 5]. In contrast, primary isolated myocardial tuberculosis, not present in other organ systems, is very rare [4, 6].
The differential diagnosis includes other granulomatous disorders like the sarcoidosis and the granulomatous giant cell myocarditis, syphilitic gummas, fungal infections, rheumatic fever, rheumatoid arthritis, metastatic tumors containing giant cells like osteosarcoma and Hodgkin's disease, and abscesses. Diagnosis of myocardial tuberculosis is based on (1) histologic evidence of typical granulomas containing a caseous center with epitheloid cells, Langhans-giant cells, and surrounding lymphocytes, (2) identification of Mycobacterium tuberculosis, and (3) tuberculous infection of other organ systems. In the present case, the large extent of calcification of the capsule suggests that the initial infection occurred many years ago. We would not expect to find viable bacteria in older granulomas. Additionally, heart tissue rarely tests positive for acid-fast bacilli, despite often positive evidence of acid-fast bacilli in other organ systems [4, 6].
The reported case gives evidence that a myocardial tuberculoma of a non-infectious grade may rapidly cause hemodynamic disturbance. It can result in destruction of the mitral valve, formation of a ventricular aneurysm [4, 5], or rupture of the ventricular wall [7]. In the absence of preoperative infection symptoms, chalky tumor of unknown etiology at the left ventricle caused the suspicion of a myxoma. The acute onset of the symptoms is typical for a myxoma moving through the atrioventriculous junction and causing obstruction of the left atrial outflow tract. The surgical resection of the intramural tuberculoma resulted in good hemodynamic recovery of the left ventricle wall lesion with beginning mitral incompetence. The antituberculous chemotherapy was started on an opened tuberculoma to prevent hematogenous distribution and the systemic infection of other organs. After 9 months without signs of recurrent tuberculous infection, the necessity for continuation of antituberculous chemotherapy should be discussed.
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Footnotes
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Address reprint requests to Dr Beyersdorf, Abteilung für Herzund Gefäßchirurgie, Albert-Ludwigs-Universität Freiburg, Hugstetter Str 55, 79106 Freiburg i Br, Germany.
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References
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- Kinare SG, Deshmukh MM. Complete atrioventricular block due to myocardial tuberculosis. Arch Path 1969;88:684–7.[Medline]
- Tuberculosis morbidity—United States, 1992. MMWR Morb Mortal Wkly Rep 1993;42:696–697, 703–4.[Medline]
- Estimates of future global tuberculosis morbidity and mortality. MMWR Morb Mortal Wkly Rep 1993;42:961–4.[Medline]
- Rose AG. Cardiac tuberculosis. Arch Pathol Lab Med 1987;111:422–6.[Medline]
- Daxini BV, Mandke JV, Sharma S. Echocardiographic recognition of tubercular submitral left ventricular aneurysm extending into left atrium. Am Heart J 1990;119:970–2.[Medline]
- Kapoor OP, Mascarenhas E, Rananaware MM, Gadgil RK. Tuberculoma of the heart. Am Heart J 1973;86:334–40.[Medline]
- Halim MA, Mercer EN, Guinn GA. Myocardial tuberculoma with rupture and pseudoaneurysm formation: successful surgical treatment. Br Heart J 1985;54:603–4.[Abstract/Free Full Text]
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Abstract
Introduction
