Intracardiac left atrial tuberculoma in an eleven-month-old infant: case report
BMC Infectious Diseases
Intracardiac left atrial tuberculoma in an eleven- month-old infant: case report
Cantinotti M 2
De Gaudio M 0 1
de Martino M 0 1
Assanta N 2
Moschetti R 2
Veneruso G 0 1
Crocetti M 2
Murzi B 2
Chiappini E 0 1
Galli L 0 1
0 Department of Sciences for Woman and Child's Health, University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
1 Department of Sciences for Woman and Child's Health, University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
2 G. Monasterio Tuscan Foundation, Heart Hospital, National Research Institute , Massa , Italy
Background: Cardiac tuberculosis is rare and usually manifests as tuberculous pericarditis. Involvement of other part of the heart is unusual and descriptions in the pediatric literature are confined to few case reports regarding mainly myocardial tuberculosis. Case presentation: We describe a case of pulmonary miliary tuberculosis associated with intracardiac left atrial tuberculoma in an immunocompetent eleven-month-old infant successfully treated with surgery and antituberculous therapy. Conclusion: Although unusual, involvement of endocardium in disseminated tuberculosis should be kept in mind.
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Background
Tuberculosis (TB) is one of the top ten causes of death
among children worldwide and it is a direct
consequence of adult TB [1]. In the natural history of
childhood pulmonary TB, primary infection before two years
of age frequently progresses to disease within twelve
months [2]. Young age and human immunodeficiency
virus type 1 (HIV-1) infection are the most important
risk factors for severe or disseminated disease [2,3]. The
involvement of the heart in TB is a very rare clinical
condition both in adults and children [4,5]. We report
here a case of pulmonary miliary TB associated with
intracardiac left atrial tuberculoma in an
eleven-monthold infant successfully treated with surgery and
antituberculous therapy.
Case presentation
An eleven-month-old female infant was referred to her
local hospital for a 2-week history of intermittent fever,
cough, dyspnea, night sweats and poor feeding. She was
initially treated with amoxicillin-clavulanic acid for
presumed upper respiratory tract infection without
improvement.
On examination, she was underweight for age, had a
temperature of 37.5C, pulse was regular with a rate of
130 beats per minute, blood pressure was normal,
transcutaneous oxygen saturation was 96% on room air, and
respiration rate was 40 breaths per minute. A few
crackles were heard bilaterally and a mild systolic
murmur was noted. She had soft, mobile, non tender, small
volume cervical lymph nodes with normal overlying skin
and no evidence of discharge. The rest of the clinical
examination was unremarkable. A complete blood count
at presentation revealed a hemoglobin of 10.4 mg/dL,
white cell count of 18 103 cell/L with neutrophilia,
and a platelet count of 660 103cell/L. Both
biochemistry profile and C reactive protein levels were normal.
HIV-1 serology was nonreactive. Chest X-Ray (CXR)
revealed diffuse, bilateral, small lung nodules which
could suggest acute pulmonary miliary TB (Figure 1).
The tuberculin skin test (TST) and the
QuantiFERONTB Gold test were negative. Results of acid-fast bacilli
(AFB) smears on three early morning gastric aspirates
were negative. Polymerase chain reaction (PCR) for
Mycobacterium tuberculosis complex and colture on
gastric aspirates were pending. Family members were
investigated for TB, but both parents had negative CXR and
TST and the source of infection was not identified.
On day 3 after admission due to the presence of a
mild systolic murmur and the persistence of
intermittent dyspnea, echocardiography (ECHO) was performed
Figure 1 Chest X-Ray. Diffuse, bilateral, small lung nodules
suggestive of acute miliary pulmonary tuberculosis.
and revealed a voluminous left atrial intracavitary
pedunculated mass prolapsing during the diastole from the
right lower pulmonary vein into the left ventricle
through the mitral valve (Figure 2). No mitral stenosis
and only trivial mitral regurgitation were noted. The
patient was immediately transferred to the
cardio-surgical unit and complete excision of an homogeneous and
yellowish in color mass was performed through median
sternotomy, under cardiopulmonary bypass.
Histopathological examination of the removed mass revealed
fibrotic tissue with mixed inflammatory cells and necrotic
debris with a vaguely granulomatous appearance and
AFBs were found. PCR for Mycobacterium tuberculosis
complex was positive on the removed mass and on
previous gastric aspirates.
Three days after surgery, a chest computed
tomography (CT) scan revealed widespread miliary nodules,
compatible with acute pulmonary miliary TB and
showed a right upper lobe consolidation (Figure 3). The
cranial contrast-enhanced CT scan and the abdominal
ultrasound were normal.
Antituberculous therapy with streptomycin (20 mg/kg
intramuscularly once d (...truncated)