Ann Thorac Surg 1999;67:226-228
© 1999 The Society of Thoracic Surgeons
Case Reports
Intracardiac tuberculoma
Byung-Chul Chang, MDa,
Jong-Won Ha, MDb,
Jung-Taek Kim, MDa,
Namsik Chung, MDb,
Sang-Ho Cho, MDc
a Division of Cardiovascular Surgery, Yonsei Cardiovascular Center, Seoul, South Korea
b Division of Cardiology, Yonsei Cardiovascular Center, Seoul, South Korea
c Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
Accepted for publication June 8, 1998.
Address reprint requests to Dr Chang, Division of Cardiovascular Surgery, Yonsei Cardiovascular Center, Yonsei University College of Medicine, CPO Box 8044, Seoul, Korea 120-752
e-mail: (bcchang{at}yumc.yonsei.ac.kr)
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Abstract
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We examined a case of endocardial tuberculoma at the proximal superior vena cava and the right atrium in a 17-year-old male patient. He had frequent palpitations and general weakness for about 7 months and was referred for evaluation of incessant atrial tachyarrhythmia. Results of echocardiography and magnetic resonance imaging showed an intracardiac mass, which was excised using cardiopulmonary bypass. Histology of the mass was consistent with the diagnosis of tuberculoma. The patient’s postoperative course was uneventful and he was discharged with antituberculous medication. Five months after the operation, the patient was well without tachycardia, and follow-up echocardiography showed complete disappearance of the mass.
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Introduction
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A 17-year-old male patient in whom cardiac arrhythmia and miliary pulmonary tuberculosis were diagnosed was referred to Yonsei Cardiovascular Center. He had had frequent palpitations and general weakness for about 7 months. He visited a private clinic, where miliary pulmonary tuberculosis was noted on his chest x-ray. During a fiber bronchoscopic procedure to evaluate his lung conditions, paroxysmal tachyarrythmia developed and the patient was referred for evaluation of incessant atrial tachyarrhythmia.
On physical examination, body temperature was 37.3°C and blood pressure was 115/70 mm Hg. Pulse was regular with a rate of 114 beats per minute. The jugular vein was distended. The breathing sound was clear. First and second heart sounds were normal. There was no pericardial rub or heart murmur. The liver and spleen were not palpable. There was no edema in the legs. Chest radiograph disclosed small interstitial nodular infiltration through both lung fields, suggestive of miliary tuberculosis. Tuberculosis skin test was positive, and antituberculosis medication was started. Sputum smear and culture for acid-fast-bacilli were negative. Electrocardiography during palpitation revealed atrial tachycardia with varying degrees of atrioventricular conduction (Fig 1), which was treated with digoxin and verapamil. Echocardiography demonstrated an echogenic mass at the proximal superior vena cava and the right atrium. It was elongated caudally with heterogeneous echogenicity (Fig 2). Coronary arteriography revealed no abnormal feeding vessel to the intracardiac mass. Percutaneous biopsy under echocardiographic guidance revealed a fragment of fibrous tissue. After 6 weeks of antituberculous medication, the number and size of pulmonary nodules in both lung fields were reduced, but the tumor size was unchanged. Surgical resection was planned, with the mass expected to be angiosarcoma or rhabdomyosarcoma.
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Fig 1. Preoperative electrocardiogram demonstrates atrial tachycardia with varying degrees of atrioventricular conduction. The atrial rate is 150 beats per minute.
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Fig 2. Multiplane transesophageal echocardiogram at 92 degrees shows a large echogenic mass (white arrows) attached at the superior portion of the right atrium with partial obstruction of the superior vena cava. (LA = left atrium; RA = right atrium; SVC = superior vena cava.)
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After a midline sternotomy incision, the pericardium was incised. The pericardium was thickened, and dense pericardial adhesion was noted especially around the right atrium and the superior vena cava. After heparin administration, the aortic cannula was inserted through the distal ascending aorta. A right-angle caval cannula was inserted through the distal superior vena cava, and another venous cannula was inserted through the lower right atrium for the inferior vena cava. After institution of a cardiopulmonary bypass, the right atrium was opened vertically while the heart was still beating. A yellowish-brown mass measuring about 2 x 2 x 3 cm was noted in the right atrium. The mass was attached to the junction of the superior vena cava and the right atrium (Fig 3). The frozen section of the mass revealed a granuloma with caseous necrosis consistent with tuberculosis. The mass was excised partially, and after repair of the right atrium, the cardiopulmonary bypass was discontinued. The permanent sections of the endocardial mass demonstrated hyalinized fibrous tissue extensively involved by coalescent granuloma and multifocal necrosis (Fig 4). However, acid-fast bacilli and periodic acid-Schiff stains for tuberculosis were negative.
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Fig 3. Surgical view demonstrates thickened pericardium and the yellowish-brown mass at the right atrium (white arrows). (Ao = aorta; IVC = inferior vena cava.)
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Fig 4. Light microscopic findings show ill-defined granuloma with central caseation necrosis and infiltrations of epithelioid cells and lymphocytes consistent with tuberculosis. (Hematoxylin-eosin stain; x100 before 49% reduction.)
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Early in the postoperative course, sinus tachycardia was noted and it was treated with verapamil and propranolol. The patient recovered uneventfully and was discharged on postoperative day 8 with antituberculosis medication (isoniazide 400 mg, pyrazinamide 1,500 mg, rifampin 600 mg, and streptomycin 1 g/day). Five months after the operation, the patient was doing well without tachycardia, and follow-up echocardiography revealed complete disappearance of the mass with normal diameter of the superior vena cava (Fig 5).
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Fig 5. Multiplane transesophageal echocardiogram after 5 months of antituberculosis medication reveals complete disappearance of the mass and normal diameter of the superior vena cava. (LA = left atrium; RA = right atrium; SVC = superior vena cava.)
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Comment
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Endocardial tuberculoma is extremely rare, found in only 19 of 13,658 autopsy cases (0.14%) [1]. Autopsy studies carried out before the introduction of specific antituberculous therapy assert that the myocardium is involved in less than 0.30% of patients dying of tuberculosis [2]. Cardiac tuberculosis is usually found at postmortem examination [1–3]. Organ involvement was classified as being either miliary (numerous small tubercles each less than 3 mm in diameter and resulting from blood-spread infection) or nodular (large rounded tuberculous lesions formed by confluent foci of tuberculous infection). Nodular myocardial tuberculosis might develop into a ventricular aneurysm [1]. True aneurysm formation due to myocardial tuberculosis is very rare. Halim and associates [4] reported a case of successful surgical treatment for a ruptured myocardial tuberculosis. The myocardium might be affected by direct spread from a mediastinal gland, by the lymphatic routes, or by the bloodstream [2]. This patient initially had miliary pattern pulmonary tuberculosis, and then it may have spread directly to the pericardium and myocardium.
Preoperatively, cardiac tuberculoma could not be diagnosed because the results of two endomyocardial biopsies under transesophageal echocardiographic guidance suggested only intracardiac tumor with fibrosis. The presumptive diagnosis preoperatively was right atrial angiosarcoma or rhabdomyosarcoma.
Clinical presentations of tuberculosis of the heart include pulmonary vein obstruction caused by left atrial mass lesions, right ventricular outflow tract obstruction, superior vena cava obstruction, aortic insufficiency, and cardiac arrythmia [2, 5, 6]. Arrythmia is a manifestation in patients with cardiac tuberculosis. Ventricular tachyarrythmia was found in a patient with right ventricular involvement of tuberculosis [5].
The treatment for cardiac tuberculosis is principally antituberculous medication. After histologic diagnosis with partial excision, the antituberculosis therapy was successful in this case. Close follow up with repeated two-dimensional echocardiography and 24-hour Holter monitoring, 24 months after the operation revealed complete disappearance of both the mass in the right atrium and the tachyarrhythmia. Although tuberculous involvement of the heart is rare, it should be suspected in patients with a cardiac mass who have active pulmonary tuberculosis and cardiac arrythmia.
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References
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Rose A.G. Cardiac tuberculosis: a study of 19 patients. Arch Pathol Lab Med 1987;111:422-426.[Medline]
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Horn H., Saphir O. The involvement of the myocardium in tuberculosis: a review the literature and report of three cases. Am Rev Tuberc 1935;32:492-506.
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Kannangara D.W., Salem F.A., Rao B.S., Thadepalli H. Cardiac tuberculosis: TB of the endocardium. Am J Med Sci 1984;287:45-47.
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Halim M.A., Mercer E.M., Guinn G.A. Myocardial tuberculoma with rupture and pseudoaneurysm formation—successful surgical treatment. Br Heart J 1985;54:603-604.[Abstract/Free Full Text]
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O’Neill P.G., Rokey R., Greenburg S., Pacifico A. Resolution of ventricular tachycardia and endocardial tuberculoma following antituberculous therapy. Chest 1991;100:1467-1469.[Abstract/Free Full Text]
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Soyer R., Brunet A., Chevallier B., Leroy J., Morere M., Redonnet M. Tuberculous aortic insufficiency: report of a case with successful surgical treatment. J Thorac Cardiovasc Surg 1981;82:254-256.[Abstract]
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Abstract
Introduction
