Bicaval obstruction complicating right atrial tuberculoma:the diagnostic value of Cardiovascular MR
Ashraf M Anwar
Youssef FM Nosir
Mohammed AR Chamsi-Pasha
Department of Medicine, King Fahd Armed Forces Hospital
Department of Cardiology, King Fahd Armed Forces Hospital
Department of Radiology
Department of medicine, King Abdul Aziz University
, King Fahd Armed Forces Hospital
Cardiac tuberculosis is rare and usually involves the pericardium. Myocardial tuberculoma is a very rare occurrence and only a few cases were reported. We describe the use of cardiovascular magnetic resonance in the diagnosis of a rare case of cardiac tuberculoma involving the right atrium which was complicated by a bicaval obstruction. The patient made a remarkable improvement with the anti-tuberculous treatment. To our knowledge, this complication has never been reported in relation to cardiac tuberculoma.
Tuberculosis can involve a multitude of organ tissues but
generally affects the respiratory tract. Involvement of the
atria with cardiac tuberculoma is exceptionally rare .
We report a case of a bicaval obstruction in a young
patient with cardiac tuberculoma.
The case highlights not only the description of a
previously unreported complication of cardiac tuberculoma,
but also the use of Cardiovascular Magnetic Resonance
(CMR) in establishing the diagnosis.
A 25-years old male, previously well, presented with
fatigue, sweating, shortness of breath on exertion and
weight loss over a 4-months period. During the last two
weeks prior to admission he developed atypical chest
pain, cough and hemoptysis. There was no relevant past
Clinical examination was unremarkable apart from right
apical bronchial breathing with no signs of superior vena
cava (SVC) obstruction. ECG showed incomplete RBBB,
sinus tachycardia with left anterior fascicular block. Chest
X ray demonstrated right apical infiltration. Both
complete blood count & biochemistry profile were normal.
Erythrocyte sedimentation rate was 65 and C reactive
protein 58. Sputum culture was positive for acid fast
bacilli. Bronchial biopsy showed granulomatous
inflammation of bronchial mucosa in keeping with tuberculosis.
Protein C & S were normal
Transthoracic echocardiography showed dilated right
atrium (RA) with a large "horse-shoe" mass involving
most of the RA wall (Figure 1a). CT scan showed
confluent ill-defined areas of consolidation with multiple
thinwalled cavitations at the upper lobe of the right lung and
multiple mediastinal and hilar lymph nodes (Figure 2).
CMR showed extensive soft tissue mass involving the right
atrial wall circumferentially with complete SVC
obstruction and partial inferior vena cava (IVC) obstruction. The
azygos vein was dilated consistent with SVC obstruction
(Figure 3a, b, c). The late gadolinium-enhanced images
showed diffuse enhancement within the mass indicating
necrosis or inflammation (Figure 4). Cardiac biopsy was
requested but the patient declined.
A diagnosis of cardiac tuberculoma predominately
involving the RA and both SVC and IVC with possible secondary
thrombus was made. The patient received
anti-tuberculosis as well as anticoagulation therapy and there was
remarkable improvement of symptoms. Follow up
echocardiography (Figure 1b) and CMR (Figure 3d, e, f)
12 months after the start of therapy showed significant
reduction of the mass and partial resolution of the IVC
obstruction but the SVC obstruction remains.
Single or multiple cardiac tuberculomas are rare and most
often observed in the right heart chambers, particularly in
the RA wall. They are usually well circumscribed and
sharply demarcated from the surrounding parenchyma
[1,2]. They may erode the underlying myocardium,
resulting in ulcers that in turn cause thrombus formation and
subsequent embolism .
To our knowledge, this is the first report of a bicaval
obstruction secondary to cardiac tuberculoma. Most cases
of superior vena cava obstruction are caused by malignant
Two-dimensional echocardiography showed the
large right atrial (RA) mass (arrows) on apical
4chambers view (A) and almost complete resolution
after the treatment (B).
eFCnihglaeursrgteCd2Tmsecdainassthinoawlelydmrpighhntoludnegs c(Bo)nsolidation (A), with
Chest CT scan showed right lung consolidation (A),
with enlarged mediastinal lymph nodes (B).
mediastinal neoplasms, especially bronchogenic
carcinoma and less frequently by a non-malignant lesion such
as mediastinal tuberculosis or goiter . Walker et al
reported a case of an acute bicaval obstruction as a result
of intracapsular haemorrhage in a right atrial myxoma .
This case showed an unusual cardiac complication of
tuberculosis not only involving the RA but also causing an
obstruction of both superior and inferior vena cava. CMR
played an important role in the initial diagnosis and the
follow up of this patient.
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-chief of this journal.
sFCmuiMogpneuRtrrhibeosar3laavfnteecnread(dcga,rveaa,df(i)eshnot-retcahroroimwa),geasndininafxeirailo(ra)v,esnaagicttaavla(b(l)oanngdarcroorwon)ablevfioerwest(rce)atsmhoewntedantdhethme acsosr(rMes)pionnrdiginhgt iamtraiugems (1R2A-),
CMR balanced gradient-echo images in axial (a), sagittal (b) and coronal views (c) showed the mass (M) in right
atrium (RA), superior vena cava (short arrow), and inferior vena cava (long arrow) before treatment and the
corresponding images 12-months after (d, e, f).
The authors declare that they have no competing interests.
IAN interpreted and analyzed MRI data. AMA drafted and
formatted the manuscript according to journal
instructions. AA was the primary physician of the patient. MAR
ceFConiMghrouaRnrecaeealr4malnyedn(aat)xwaianitldhsielnactteihoe(nbms)saghsaosd wo(aleirndriounwmos-n)e-nhhoamnocegedniomuasges in
CMR early (a) and late (b) gadolinium-enhanced
images in coronal and axial sections showed
nonhomogenous enhancement within the mass (arrows).
was a medical intern collected the clinical data. YFN
performed and reported the echocardiographic findings. AA
contributed to the analysis of CT and MRI findings. HCP
reviewed the whole manuscript before submission.