Tuberculosis is widely prevalent among children in India, especially in those with coexisting
severe malnutrition and immunodeficiency. Uncommon sites for tuberculosis are frequently
seen. However, intracardiac tuberculomas are extremely rare in children. To the best of our
knowledge, this is the first case report of multiple asymptomatic intracardiac tuberculomas in
a child. Most intracardiac tuberculomas cause symptoms, especially in adults. In asymptomatic
children non surgical management of intracardiac tuberculomas appears to be a safe
treatment option as complete resolution occurs with antituberculous therapy. (Cardiol J 2012;
19, 5: 518-520

Dubey, AnandPrakash

Gera, Rani

Gupta, Sandya

Rajeshwari, Krishnan

English

Via Medica Journals

CASE REPORTCardiology Journal2012, Vol. 19, No. 5, pp. 518–52010.5603/CJ.2012.0094Copyright © 2012 Via MedicaISSN 1897–5593518 www.cardiologyjournal.orgAddress for correspondence: Prof. Krishnan Rajeshwari, Department of Pediatrics, Maulana Azad Medical College,New Delhi 110002, India, tel: 9968604312, e-mail: rajeshwari.dr@gmail.comReceived: 08.07.2011 Accepted: 21.07.2011Asymptomatic multiple intracardiactuberculomas in a childKrishnan Rajeshwari, Sandya Gupta, AnandPrakash Dubey, Rani GeraDepartment of Pediatrics, Maulana Azad Medical College, New Delhi, IndiaAbstractTuberculosis is widely prevalent among children in India, especially in those with coexistingsevere malnutrition and immunodeficiency. Uncommon sites for tuberculosis are frequentlyseen. However, intracardiac tuberculomas are extremely rare in children. To the best of ourknowledge, this is the first case report of multiple asymptomatic intracardiac tuberculomas ina child. Most intracardiac tuberculomas cause symptoms, especially in adults. In asympto-matic children non surgical management of intracardiac tuberculomas appears to be a safetreatment option as complete resolution occurs with antituberculous therapy. (Cardiol J 2012;19, 5: 518–520)Key words: intracardiac tuberculomas, childrenCase reportTuberculosis is widely prevalent among chil-dren in India, especially in those with coexistingsevere malnutrition and immunodeficiency. Uncom-mon sites for tuberculosis are frequently seen.However, intracardiac tuberculomas are extreme-ly rare in children. We report an unusual case ofmultiple intracardiac tuberculomas in a child.An eight year-old boy presented with a historyof low grade fever and progressive weight loss ofone year’s duration. There was history of associat-ed cough without expectoration for the same dura-tion. There was no history of palpitations or dysp-nea. He had been taken to various private doctorsand received multiple courses of antibiotics but norelief was obtained. Six months later, the child de-veloped one episode of generalized tonic clonic sei-zure lasting 15 min for which carbamazepine wasstarted. On examination in this hospital, the childhad anemia, no lymphadenopathy, jaundice or club-bing. Heart rate was 80 bpm, regular and blood pres-sure was 90/60 mm Hg. He was severely malnour-ished with wasting and stunting with a weight of16 kg and height of 119 cm. He also had micro-cephaly with a head circumference of 48 cm. Chestexamination revealed bilateral occasional crackles.There was no hepatosplenomegaly. Cardiovascularexamination was within normal limits. The childalso had mental retardation.Investigations revealed normocytic normo-chromic anemia (Hb 8.6 g/dL), total leukocyticcount of 10,440 cells per mL, erythrocyte sedimen-tation rate of 60 mm in first hour. Kidney functiontests and liver function tests were within normallimits. Mantoux test was reactive. Serological test-ing for HIV infection was negative. Chest X-rayshowed cardiomegaly with widening of carina. Bonycage and soft tissue were normal. Infiltrative opaci-ties were seen in the right upper zone and middlezone and a right lamellar effusion was seen. Two--dimensional echocardiography revealed a largemass in the right atrium (RA), left atrium (LA) andleft ventricle (LV) with normal valves. Magneticresonance imaging (MRI) of the heart revealed het-erogeneously enhancing thickened myocardiumwith associated heterogeneously enhancing intralu-minal masses in RA, LA and LV minimal pericar-519Krishnan Rajeshwari et al., Intracardiac tuberculomas in a childwww.cardiologyjournal.orgdial effusion and associated ill defined heteroge-nously enhancing soft tissue in anterior, middle andposterior mediastinum and right paravertebral softtissue with bony destruction of costovertebral junc-tion and signal alteration in vertebral bodies (Fig. 1).Right sided empyema with minimal left pleural ef-fusion and fibronodular lesions in bilateral lungfields were seen. This MRI was suggestive of pul-monary tuberculosis, with mediastinal involvementalong with multiple intracardiac tuberculomas (Fig. 2).Category 1 antitubercular treatment comprising iso-niazid, rifampicin, ethambutol and pyrazinamide wasstarted. Fever gradually resolved and the child im-proved. Repeat MRI done two months later showedthat the mass lesions in the atria and LV had de-creased in size and anterior, middle and posteriormediastinum showed liquefaction. The sternal andchest wall involvement had increased. The child wassubsequently discharged. Fifteen days later, he de-veloped an abscess right chest wall which was diag-nosed as empyema necessitans. This was drainedand pus was negative for acid fast bacilli stain. Re-peat echo done three months after anti tuberculartherapy showed a normal heart with resolution of alltuberculomas (Fig. 3). This confirmed the etiologyas tubercular, as he had only received antitubercu-lar treatment in the preceding three months.DiscussionTo the best of our knowledge, this is the firstcase report of multiple asymptomatic intracardiactuberculomas in a child.Among the extrapulmonary manifestationsof tuberculosis, involvement of the heart is ex-tremely rare and very infrequently diagnosed antemortem [1]. In a series of 14,000 deaths due to tu-berculosis, involvement of the heart was observedin less than 0.5% of cases [2]. Three distinct formsare recognized: diffuse infiltrating, miliary, andnodular [3].Figure 1. Magnetic resonance imaging of the heart sho-wing heterogeneously enhancing thickened myocar-dium with associated heterogeneously enhancing intra-luminal masses in right and left atrium and left ventricleand minimal pericardial effusion and associated ill defi-ned heterogenously enhancing soft tissue in anterior,middle and posterior mediastinum.Figure 3. Post treatment echo showing complete reso-lution of intracardiac tuberculomas.Figure 2. Magnetic resonance imaging was suggestiveof pulmonary tuberculosis, with mediastinal involve-ment along with multiple intracardiac tuberculomas.520Cardiology Journal 2012, Vol. 19, No. 5www.cardiologyjournal.orgAlthough involvement can occur from he-matogenous spread, the most likely mechanisms ofmyocardial involvement are direct retrogradespread from a contiguous mediastinal lymph nodeor extension from a pericardial focus [4]. This childalso had extensive mediastinal and pulmonary tu-berculosis. Single or multiple cardiac tuberculomasare most often observed in the right heart cham-bers, particularly in the wall of the RA. They areusually well circumscribed and sharply demarcat-ed from the surrounding parenchyma. They mayerode the underlying myocardium, resulting in ul-cers that in turn cause thrombus formation and sub-sequent embolism. Most clinical reports publishedhave described various symptoms in adults due tocardiac tuberculosis, like ventricular tachycardia[5, 6], aortic insufficiency [7], pulmonary vein ob-struction caused by LA mass lesion [8], completeheart block [9], congestive heart failure [10], rightventricular outflow tract obstruction [11], and su-perior vena cava obstruction [12]. This child had nocardiac symptoms at presentation.Whereas the diagnosis of tuberculosis was al-most exclusively made at autopsy in earlier years,advances in imaging techniques give an opportunityfor earlier diagnosis. Echocardiography, computedtomography and MRI contribute to an optimal mor-phologic description and assessment of hemodyna-mic significance. Cardiac MRI is a recent tool andshows a characteristic T2 shortening in tuberculousinvolvement, similar to that seen in intracranial tu-berculomas. The characteristic appearance on T2Wimages includes a central isointense core, corre-sponding to central caseation; a hypointense rim,which represents the fibrous capsule; and a thin hy-perintense line, which correlates with an inflamma-tory cellular infiltrate [13]. This was seen in this case.To conclude, in areas of high prevalence of tu-berculosis in children with extensive chest tubercu-losis, multiple cardiac masses should be consideredto be tubercular in origin. Histopathological evidencemay not always be possible to obtain. MRI of theheart is emerging as a recent important diagnostictool. Resolution with antitubercular treatment canbe demonstrated by serial echocardiography. Mostintracardiac tuberculomas cause symptoms, especial-ly in adults. However, even multiple intracardiacmasses may be completely asymptomatic, as seenin this child. In asymptomatic children, non surgicalmanagement of intracardiac tuberculomas appears tobe a safe treatment option.AcknowledgementsDr K. Rajeshwari wrote the manuscript,Dr A.P. Dubey assisted in the drafting and the resthelped in data collection.Conflict of interest: none declaredReferences1. Kannangara DW, Salem FA, Rao BS, Thadepalli H. Cardiac tu-berculosis: TB of the endocardium. Am J Med Sci, 1984; 287:45–47.2. Custer EN, Charr R. Tuberculosis of the myocardium. JAMA,1939; 112: 1333–1334.3. Gaultier Y, Alou A, Cenac A, Develoux M, Vetter JM. Tuberculomedu Coeur [In French]. Arch Mal Coeur, 1987; 80: 1413–1416.4. Murtada AH, Mercer EN, Guinn GA. Myocardial tuberculomawith rupture and pseudoaneurysm formation: Successful surgi-cal treatment. Br Heart J, 1985; 54: 603–604.5. Neill PGO, Rokey R, Greenberg S, Pacifico A. Resolution ofventricular tachycardia and endocardial tuberculoma followingantituberculosis therapy. Chest, 1991; 100: 1467–1469.6. Behr G, Palin HC, Temperley JM. Myocardial tuberculosis. BrMed J, 1977; 1: 951.7. Soyer R, Brunet A, Chevallier B, Leroy J, Morere M, Redonnet M.Tuberculous aortic insufficiency: Report of a case with success-ful surgical treatment. J Thorac Cardiovasc Surg, 1981; 82:254–256.8. Horn H, Saphir O. The involvement of the myocardium in tuber-culosis: A review of literature and report of three cases. Am RevTuberc, 1935; 32: 492–506.9. Wren C, Stovin, PG. Isolated interventricular septal tuberculo-ma causing complete heart block. Thorax, 1982; 37: 149–150.10. Krishnaswami H, Cherian G. Right atrial tuberculoma: Report ofa case with complete recovery. Thorax, 1984; 39: 550–551.11. Rawls WJ, Shuford WH, Logan WD, Hurst JW, Schlant RC. Rightventricular outflow tract obstruction produced by a myocardialabscess in a patient with tuberculosis. Am J Cardiol, 1968; 21:738–745.12. Kapoor OP, Mascarenhas E, Rananaware MM, Gadgil RK. Tu-berculoma of the heart. Report of 9 cases. Am Heart J, 1973;8693: 334–340.13. Kim TK, Chang KH, Kim CJ, Goo JM, Kook MC, Han MH.Intracranial tuberculoma: Comparison of MR with pathologicfindings. Am J Neuroradiol, 1995; 16: 1903–1908.

Asymptomatic multiple intracardiac tuberculomas in a child

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Asymptomatic multiple intracardiac tuberculomas in a child

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