Natalia Smirnova, MD
Emory University School of Medicine
Atlanta, Georgia
Disclosure information not submitted.
Pedro Lamothe, MD, PhD
Pulmonary/Critical Care Fellow
Emory University School of Medicine, United States
Disclosure information not submitted.
Abiodun Kukoyi, MD
Assistant Professor, Pulmonary & Critical Care Medicine
Emory University School of Medicine, United States
Disclosure information not submitted.
Title: Intracardiac Mass in a Patient with Pulmonary Tuberculosis
Introduction: Tuberculosis (TB) is one of the leading infectious causes of mortality worldwide. In the United States, it is rarely seen in immunocompetent patients without risk factors. TB presents clinically in many ways and on rare occasions affects the heart. Here, we present a case of pulmonary TB resulting in respiratory failure and an intracardiac mass.
Description: A 31-year-old woman with asthma presented to the emergency room with three weeks of fever and productive cough. She was admitted after a chest CT scan showed cavitary lesions and extensive destruction of the right lung. Her initial sputum sample was negative for acid-fast bacilli (AFB) but four subsequent samples stained positive. Although she had no risk factors for TB and no immunosuppression, PCR confirmed Mycobacterium tuberculosis with normal susceptibilities. She was initiated on isoniazid, rifampin, ethambutol, and pyrazinamide. Three days later, she was admitted to the intensive care unit following intubation for respiratory failure. She was later noted to have left-sided weakness and right gaze preference. Neuroimaging showed an acute right middle cerebral artery stroke and multiple smaller embolic strokes. A transthoracic echocardiogram (TTE) revealed a large left ventricular (LV) intracardiac mass, new compared to TTE four days prior. Given suspicion for a possible intracardiac tuberculoma with septic embolization, and risk for hemorrhagic conversion, the decision was made to not initiate heparin. Hemodynamic instability precluded the patient from undergoing a cardiac MRI or surgical intervention. After a long and complicated hospital course, the patient was discharged home with residual left side hemiparesis.
Discussion: Cardiac involvement with TB is uncommon and when present, mostly involves the pericardium. For this patient with active tuberculosis who developed an intracardiac and subsequent systemic embolic events, there are three possible explanations, all of which are rare: 1) An intracardiac tuberculoma, 2) an LV thrombus that formed despite a normal ejection fraction and the absence of other cardiac structural anomalies, 3) a thrombus that originated in the pulmonary veins and migrated to the LV. In the setting of severe systemic disease with TB, atypical clinical presentations should remain on the differential.