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Circulation. 2007;116:e1
doi: 10.1161/CIRCULATIONAHA.106.677120
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(Circulation. 2007;116:e1.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

An Unusual Site for a Common Disease

Maysaa Alzetani, MRCP, MSc; Joseph J. Boyle, MRCP, PhD; David Lefroy, MA, MB, BChir, FRCP; Petros Nihoyannopoulos, MD, FRCP

From the Hammersmith Hospital NHS Trust (M.A.), and the Histopathology Department (J.J.B.) and Hammersmith Hospital (D.L., P.N.), Imperial College, London, UK.

Correspondence to Dr Maysaa Alzetani, 42 Tryfan Close, Ilford, London IG4 5JY, United Kingdom. E-mail maysaazetani{at}msn.com

A 75-year-old Asian woman presented with a 5-month history of night sweats, lethargy, and malaise. On admission she was found to have low-grade pyrexia and elevated inflammatory markers. Septic screen, which included repeated blood cultures and chest x-ray (Figure 1), were negative. A transthoracic and transesophageal echocardiography revealed a doughnut-shaped mass (online Data Supplement Movie I) that surrounded the mitral valve annulus and extended up to the left atrial walls and atrial septum. A surgical biopsy was taken (Figure 2), which showed epithelioid and langhans giant cell granulomas with central caseating necrosis consistent with tuberculosis. Special staining with high-sensitivity immunoperoxidase confirmed the diagnosis of tuberculosis. The patient was treated for tuberculosis with complete resolution of her symptoms. Repeated echocardiography 6 months later showed a dramatic reduction of the mass size (Data Supplement Movies II and III).


Figure 1184566
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  		Figure 1. Posterior-anterior chest x-ray, taken on admission, shows clear lung fields and no signs of infection.


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  		Figure 2. Biopsy taken from the mass that surrounded the mitral valve annulus and extended up to the left atrial walls and atrial septum. Hematoxylin and eosin staining. Magnification, x20. Ep indicates epithelioid macrophages; L, Langhans giant cells; and N, necrosis. Inset, immunohistochemistry with monoclonal antibody to mycobacterium (Dako, Glostrup, Denmark) and immunoperoxidase (Menarini Diagnostic, Wokingham, UK). B indicates bacillus; M, macrophage. Magnification, x100 (cropped for space).

Isolated cardiac tuberculosis is extremely rare. However it should be included in the differential diagnosis of intracardiac masses.


*    Acknowledgments
 
Sources of Funding

Dr Boyle has received research support from the British Heart Foundation, KRUK, HHRTC, and the Broad Foundation.

Disclosures

Dr Boyle has received honoraria from the International Journal of Experimental Pathology, has served as a speaker for the Histochemical Society and the British Atherosclerosis Society as a member of the editorial board for the International Journal of Experimental Pathology, and as an expert witness to UK coroners and mesothelioma panels.


*    Footnotes
 
The online-only Data Supplement, consisting of movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/116/1/e1/DC1.


Related Article:

Issue Highlights
Circulation 2007 116: 1. [Full Text]




This Article
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