An Unusual Atrial Mass: A Case Study
An Unusual Atrial Mass: A Case Study
David F. Reilly
Christina C. Lindenmeyer
Bac Kgroun D This case highlights the evolution of a broad differential diagnosis when presented with a rare and diagnostically enigmatic clinical finding. ca SE Pr ESEn TaTion A 43-year-old Puerto Rican male with a history of homelessness,intravenousdrugabuse,andincarceration presented following an episode of syncope. His past medical history was notable for a recent diagnosis of granulomatous nephritis, thought to be secondary to isolated renal sarcoidosis. He had been treated with high dose prednisone and subsequently initiated on hemodialysis. On presentation, he complained of rigors, shortness of breath, cough, abdominal pain and coffee-ground emesis. On initial examination, the patient was ill-appearing, febrile, tachypneic and tachycardic. He was awake and oriented with no focal neurological deficits.
His sepsis evaluation included computed axial
tomography (CT) scans of his chest, abdomen and
pelvis. Imaging was notable for para-aortic
lymphadenopathy, diffuse micro-nodular densities throughout
the lungs, hilar and mediastinal lymphadenopathy, and
advanced xanthogranulomatous pyelonephritis with
extensive calcification of the right kidney. His blood
and urine cultures grew a resistant strain of Escherichia
coli and he was initiated on broad antibiotic coverage,
delivered via a central venous catheter. Further
evaluation for endocarditis included both transthoracic
(TTE) and transesophageal (TEE) echocardiograms,
which identified a well-demarcated, heterogeneous
right atrial (RA) density measuring 1.7 x 1.6 cm. He
was initiated on full anticoagulation for this presumed
catheter-associated right atrial thrombus. A head
CT demonstrated an abnormal 1.2 x 3.6 cm lobular
hyper-density in the right frontal lobe with surrounding
edema, and multiple dispersed punctate calcified
Soon after presentation, the patient developed seizures
and acute respiratory failure, necessitating intubation. His
chest x-ray demonstrated progression of innumerable
bilateral pulmonary micro-nodular densities. He
underwent bronchoscopy, and pathology was notable
for acute fibrinous and organizing pneumonia. Initial
concentrated sputum smears were negative for
acid-fast bacilli (AFB). He was, however, initiated on
empiric anti-tuberculosis quadruple pharmacotherapy
(RIPE) given his exposure risk, chronic
immunocompromised state, and concern for miliary tuberculosis.
He was eventually weaned from the ventilator and was
extubated. Subsequently, a right-sided percutaneous
nephrostomy tube was placed to relieve his obstructing
xanthogranulomatous pyelonephritis. Cultures from
the nephrostomy tube were notable for the growth
of Mycobacterium Tuberculosis Complex (MTB), as
were cultures from his bronchoscopy, confirming
disseminated MTB. His original sputum cultures later
grew MTB 19 days after collection.
Several weeks into his hospital stay, a lower
gastrointestinal bleed prompted the discontinuation of his
anticoagulation, necessitating re-evaluation of the
right atrial mass. TTE revealed an expanded (4.2 x
3.3 cm) multi-lobulated, heterogeneous echo-dense
RA mass extending towards the inferior vena cava/
RA junction with new focal areas of brightness
suggesting calcification. Hemodynamic assessment
including orthostatics and central venous pressure
estimation were normal. Although airborne precautions
precluded endoscopic evaluation of the gastrointestinal
hemorrhage, the imminent risk of the growing atrial
mass prompted reinstitution of anticoagulation, which
he was able to tolerate.
In the setting of disseminated MTB infection, the
patient’s chronic steroids were slowly tapered.
However, he quickly developed a new facial droop,
unilateral weakness and altered mental status. It was
thought that his neurological change was secondary
to tuberculous cerebritis. He was quickly re-initiated on
high dose prednisone, and his mental status improved.
He later developed recurrent polymicrobial bacteremia
from his pyelonephritis and required a prolonged
course of antibiotics. Nephrectomy was deemed to
be prohibitively high risk in the setting of his multiple
As his infections were appropriately managed, a
multidisciplinary approach in concert with cardiology,
infectious diseases, radiology and interventional
radiology was undertaken to further elucidate the
etiology of his undifferentiated atrial mass. Given his
multiple co-morbidities, poor functional status and
chronic immunosuppression, invasive diagnostics were
deferred, and it was decided that he would be continued
on empiric anticoagulation in combination with RIPE
therapy for both thrombus and atrial tuberculoma.
DiFFEr En Tial Diagno SiS
The patient presented with a previous pathological
diagnosis of renal-limited sarcoidosis and had been
treated with several months of high-dose
corticosteroids. He then developed persistent fevers,
neurological deficits, miliary pulmonary infiltrates,
calcified cerebral hyper-densities, presumed enteritis,
xanthogranulomatous pyelonephritis, and an atrial
mass. Initially, a diagnosis of systemic sarcoidosis
remained high on the differential. Given the patient’s
immunocompromised state, polymicrobial infections,
and progression of systemic manifestations on
corticosteroids, also included in the initial differential diagnosis
were lymphoproliferative disorders, neoplasms, and
infections (including disseminated tuberculosis).
An intra-cardiac mass is an uncommon finding that
carries a broad differential diagnosis, including thrombus,
vegetative endocarditis, myxoma, myosarcoma,
rhabdomyosarcoma, infiltrative lymphoma, secondary
deposits and cardiac tuberculoma.
ou Tco ME an D Foll ow -u P
Following institution of RIPE therapy for disseminated
tuberculosis, targeted antimicrobials for bacteremia,
steroids for tuberculous cerebritis and empiric
anticoagulation for his atrial mass, the patient’s clinical status
improved. He has remained hemodynamically stable,
precluding the need for surgical intervention of his atrial
mass. He will require monthly monitoring with TTE, a
prolonged course of RIPE, and long-term
anticoagulation for management of his disseminated tuberculosis
and undifferentiated right atrial mass.
The constellation of findings presented in this case
represent a broad differential diagnosis, including
systemic sarcoidosis, lymphoproliferative disorders,
and infections.1 Sarcoidosis and lymphoproliferative
disorders are known to involve the lungs, kidneys, central
nervous system, gastrointestinal tract and
reticuloendothelial system. However, the isolation of MTB from two
separate sources in an immunocompromised patient at
high risk for previous MTB exposure makes the diagnosis
of primary or reactivation disseminated tuberculosis
most likely.1-3 With strong clinical, microbiological
and radiographic evidence supporting a diagnosis of
disseminated tuberculosis, the immediate institution
of RIPE and rapid identification and management of
potential end-organ complications is paramount. 3
Less than 1.5% of all MTB infections disseminate
lymphohematogenously. Most often the lungs are affected,
but, after lymphadenopathy, the next most common
manifestations of non-pulmonary tuberculosis include
gastrointestinal and hepatic (80%), genitourinary (27%),
and meningeal (20%).1,4,5 Infiltration of the myocardium
is uncommon, and the documented incidence of
intra-cardiac tuberculoma is rare, with a majority of
cases diagnosed at autopsy.6
The few reported cases of cardiac tuberculoma
diagnosed in vivo describe single or multiple
well-circumscribed, heterogeneous masses often occupying the
right atrial free wall.6-9 Echocardiography is often used to
characterize size, location and echogenicity. Magnetic
Resonance Imaging is able to provide more detail, but
often fails to distinguish tuberculoma from thrombus
and myxoma.7 Percutaneous biopsy under
echocardiographic guidance provides a means of sampling
the mass. However, identification of characteristic
histopathological findings lacks sensitivity, and most
reports indicate unacceptable yields for identification of
MTB following Ziehl-Neelsen staining.6,7,9 A confirmatory
diagnosis requires invasive removal of the mass for
gross histopathological diagnosis.7 Few studies have
demonstrated successful reduction in size, and even
complete resolution of cardiac tuberculomas following
appropriate anti-tuberculosis pharmacotherapy alone.
6,8 Surgical intervention is indicated if the mass results
in clinically significant hemodynamic compromise, or
if diagnosis remains unclear after pharmacotherapy has
failed to demonstrate improvement by imaging.6,8,9
Given the patient’s encouraging response to
anti-tuberculosis pharmacotherapy and
anticoagulation, as well as persistently stable hemodynamics,
further diagnostics of the right atrial mass were deferred.
The risk of interventional diagnostics were thought to
outweigh any benefits, given that the treatment plan
of combining anticoagulation with RIPE therapy would
KEy Poin TS
Cardiac tuberculomas are a rare complication of
disseminated MTB infection and should be considered
in the differential diagnosis of an intra-cardiac mass
in a patient with proven MTB. With strong clinical and
radiographic evidence, and without hemodynamic
compromise, invasive diagnostics may be deferred in
favor of empiric medical management.
"Sunset over Naraganssett Bay, Rhode Island”
photograph by Andrew Zabolotsky, MD
52 | The Medicine Forum
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