A 43-year–old man with a 6-month history of cough, dyspnea, nocturnal sweats, and weight loss was reviewed in the clinic. Clinical examination revealed cervical lymphadenopathy and indicated constrictive physiology. Initial tests, including chest radiography, sputum examination, QuantiFERON-TB Gold test, and lymph node biopsy, were unyielding. HIV serology was nonreactive.
Cardiac magnetic resonance imaging (Figure 1A and 1B) demonstrated extensive tumor infiltration affecting the endocardium, myocardium, and pericardium. Transesophageal echocardiography–guided endomyocardial biopsy (Figure 2) of the tumor revealed mixed inflammatory cells with a vaguely granulomatous appearance (not shown). A pericardial biopsy via limited thoracotomy confirmed multiple centrally caseating granulomata (Figure 3). Antituberculous therapy was begun with symptom resolution. On follow-up, the patient was clinically improved. Repeat magnetic resonance imaging (Figure 4A and 4B) performed 8 months after therapy was begun confirmed almost complete disappearance of the left ventricle–encasing mass and a marked reduction in the size of the right atrial mass.
Myocardial tuberculosis, first reported by Maurocordat on autopsy in 1664, is exceedingly rare and often not diagnosed while the patient is alive. Advanced imaging techniques now enable earlier diagnosis and surveillance. Cardiac tuberculoma may regress after antituberculous therapy for 6 to 9 months, and surgery may not be needed.