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.
Tuberculosis (TB) is one of the top ten causes of death
among children worldwide and it is a direct
consequence of adult TB . In the natural history of
childhood pulmonary TB, primary infection before two years
of age frequently progresses to disease within twelve
months . 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
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
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 daily), isoniazid (10 mg/kg orally
once daily), rifampicin (15 mg/kg orally once daily),
ethambutol (20 mg/kg orally once daily), pyrazinamide
(30 mg/kg orally once daily) and corticosteroids were
started immediately with remarkable improvement in
her symptoms in two weeks. Streptomycin was
suspended once the drug susceptibility results showed no
resistance to the first-line antituberculous drugs.
Coltures of gastric aspirates and tissue specimens of the
removed mass confirmed Mycobacterium tuberculosis.
Further investigations on possible source case found a
Romanian grandmother with active pulmonary TB.
Echocardiograms were performed at regular
postoperative intervals and no residual lesions were noted.
The infant completed 1 year of antituberculous therapy,
recovered completely, and did well during the whole
To our knowledge, this is the youngest patient reported
with a cardiac tuberculoma and the first infant with an
endocardial tuberculoma in a left heart chamber
Cardiac TB is a rare disease and it most usually
manifests as tuberculous pericarditis . Involvement of
other parts of the heart is unusual and descriptions in
Figure 2 Trans-thoracic echocardiographic subcostal and
parasternal views. A voluminous left atrial intracavitary
pedunculated mass prolapsing during the diastole from the right
lower pulmonary vein into the left ventricle through the mitral
Figure 3 Chest Computed Tomography. Innumerable tiny,
welldefined, miliary nodules throughout the lungs, and bronchovascular
structures, a consolidation with air bronchogram in the posterior
segment of the right upper lobe and an initial consolidation in the
lateral segment of the right inferior lobe with evident local
the pediatric literature are confined to few case reports
regarding mainly myocardial TB [5-8]. Myocardial TB
may occur secondary to haematogenous spread from a
remote tuberculous focus, lymphatic spread from
mediastinal lymph nodes, or direct involvement from the
adjacent pericardium . Three distinct forms of
myocardial TB have been recognized: miliary, diffuse
infiltrating, or nodular with central caseation or
tuberculoma [5,9]. Tuberculoma, a mass-like
manifestation of the disease, was first reported by Morgagni in
1761 [7,9,10]. Myocardial tuberculomas are mostly
located in the right heart and particularly in the wall of
the right atrium . They are usually sharply
demarcated from the surrounding parenchyma and may be
single or multiple [4,9].
The infant we described had a miliary pattern
pulmonary TB. The infection may have spread
hematogenously to the left heart chambers causing a single
voluminous left atrial endocardial tuberculoma.
Tuberculoma of the heart has been associated to congenital
heart diseases in children, but our patient had no
anatomic abnormalities . In addition, disseminated TB is
often associated with acquired immunodeficiency
syndrome, but our patient was immunocompetent and
negative for HIV-1 .
Clinically, cardiac tuberculomas may be asymptomatic,
or presenting with pulmonary vein obstruction due to
left atrial mass lesions, left ventricular aneurysm, right
ventricular outflow tract obstruction, superior vena cava
obstruction, coronary artery occlusion, impairment of
ventricular contractility, ventricular rupture, aortic
insufficiency or regurgitation, cardiac arrhythmia, complete
heart block, and sudden cardiac death [8,9,11,12]. Our
patient presented only a systolic murmur and
The treatment of cardiac TB is, first of all,
antituberculous therapy . Complete recovery of patients signs
and symptoms along with imaging evidence of cardiac
involvement resolution on antituberculous therapy has
been reported previously . However, if the diagnosis
remains questionable or in cases of severe hemodynamic
compromise, refractory arrhythmias or threatening
thromboembolism, the surgical resection of tuberculoma
may be considered [9,13]. In 1997, Shoeman JF et al.
described an infant with miliary TB and an acute stroke
caused by an infected thromboembolus which arose
from a suspected endocardial tuberculous vegetation
. In our patient the voluminous tuberculoma
prolapsing during the diastole had a high risk of systemic
embolization and a surgical resection was immediately
performed. Subsequently, a 12-month course of
antituberculous therapy to prevent hematogenous
dissemination and to treat pulmonary parenchymal disease was
completed with total recovery.
The infant we described had a CXR suggestive of acute
miliary pulmonary TB which was supported by the chest
CT performed few days later. However TST,
QuantiFERON-TB Gold test, and microscopic examination of
gastric aspirates were negative. Only PCR and coltures of
gastric aspirates and tissue specimens of the removed
mass revealed Mycobacterium tuberculosis. This confirms
that up to 40% of immunocompetent young children
with colture-documented active TB do not react to the
TST, nor have a positive QuantiFERON-TB Gold test,
and have a less than 15% probability of having an AFB
smear positive gastric aspirate [1,15-17].
The peculiarity of TB in the pediatric population is the
imperceptible and often rapid progression from infection
with Mycobacterium tuberculosis to active disease .
As a matter of fact, the risk of progression depends on
various factors, including age at exposure, nutritional
and immune status, genetic factors, virulence of the
organism, and magnitude of initial infection .
Pulmonary parenchymal disease and intrathoracic
adenopathy are the most common clinical manifestations of
pediatric TB, accounting up to 80% of all cases [2,16].
Among extrapulmonary manifestations, cardiac TB is
extremely rare. However, negative QuantiFERON-TB
Gold test, TST, and microscopic examination on gastric
aspirates should not dissuade pediatricians from further
investigations in infants for active TB. Although rare,
disseminated TB with heart involvement should be
suspected in immunocompetent infants with an
CM and DGM drafted the manuscript together and should be both
considered first author. dMM, EC and VG participated in the design of the
paper and revised it critically for the infectious diseases content. BM, AN, MR
and MC participated in the design of the paper and revised it critically for
the cardio-surgical content. LG help to draft the manuscript and revised the
final version of the manuscript. All authors read and approved the final
1. Swaminathan S , Rekha B : Pediatric tuberculosis: global overview and challenges . Clin Infect Dis 2010 , 50 : 184 - 194 .
2. Marais BJ , Gie RP , Schaaf HS , Hesseling AC , Obihara CC , Starke JJ , et al: The natural history of childhood intra-thoracic tuberculosis: a critical review of literature from the prechemotherapy era . Int J Tuberc Lung Dis 2004 , 8 : 392 - 402 .
3. Nelson LJ , Wells CD : Global epidemiology of childhood tuberculosis . Int J Tuberc Lung Dis 2004 , 8 : 636 - 647 .
4. Licht J , Diefenbach C , Stang A , et al: Tuberculoma of the myocardium: a rare case of intra-vitam diagnosis . Clin Res Cardiol 2009 , 98 : 331 - 333 .
5. Jagia P , Gulati GS , Sharma S , Goyal NK , Gaikwad S , Saxena A : MRI features of tuberculoma of the right atrial myocardium . Pediatr Radiol 2004 , 34 : 904 - 907 .
6. Santos CL , Moraes F , Moraes CR : Obstruction of the right ventricular outflow tract caused by a tuberculoma in a patient with ventricular septal defect and aneurysm of the membranous septum . Cardiol Young 1999 , 9 : 509 - 511 .
7. Gulati GS , Singh S , Arepalli D , Sharma S , Kothari SS , Airan B , et al: Superior vena caval obstruction after complete resolution of cardiac tuberculoma . Clin Radiol 2008 , 63 : 605 - 609 .
8. Chang BG , Ha JW , Chung N : Intracardiac tuberculoma . Ann Thorac Surg 1999 , 67 : 226 - 228 .
9. Maeder M , Ammann P , Rickli H , et al: Fever and night sweats in a 22-yearold man with mediastinal mass involving the heart . Chest 2003 , 124 : 2006 - 2009 .
10. Vaideeswar P , Pandit SP , Deshpande JR : Tuberculoma of the heart . Cardiovasc Pathol 2006 , 15 : 55 - 56 .
11. O'Neill PG , Rokey R , Greenberg S , et al: Resolution of ventricular tachycardia and endocardial tuberculoma following antituberculosis therapy . Chest 1991 , 100 : 1467 - 1469 .
12. Al Nasser I , Anwar AM , Nosir YF , et al: Bicaval obstruction complicating right atrial tuberculoma: the diagnostic value of cardiovascular MR . J Cardiovasc Magn Reson 2008 , 20 : 10 - 60 .
13. Rodriguez E , Soler R , Juff A , et al: CT and MR findings in a calcified myocardial tuberculoma of the left ventricle . J Comput Assist Tomogr 2001 , 25 : 577 - 579 .
14. Schoeman JF , Rutherfoord GS , Hewlett RH : Acute stroke in a child with miliary tuberculosis . Clin Neuropathol 1997 , 16 : 303 - 308 .
15. American Academy of Pediatrics: Red Book: 2009 Report of the Committee on Infectious Disease . In Tuberculosi.. 28 edition. Edited by: Pickering LK, Baker CJ , Kimberlin DW , Long SS . Elk Grove Village, IL: American Academy of Pediatrics ; 2009 : 680 - 698 .
16. Kampmann B , Whittaker E , Williams A , et al: Interferon-gamma release assays do not identify more children with active tuberculosis than the tuberculin skin test . Eur Respi J 2009 , 33 : 1374 - 1382 .
17. Bianchi L , Galli L , Moriondo M , et al: Interferon-gamma release assay improves the diagnosis of tuberculosis in children . Pediatr Infect Dis J 2009 , 28 : 510 - 514 .