An 18-year old woman of Somalian origin was admitted with a two-months history of fatigue, poor appetite and unspecific body pain, but without fever or cough. Four months previously she arrived in Sweden. She was immunocompetent and previously healthy except for a skeletal mass on the sternum and right clavicle at the age of seven. It was considered as skeletal TB, and anti-tuberculosis treatment was given for six months without any effect.
On initial admission, blood tests showed signs of mild inflammation with ESR 49 mm and CRP 16 mg/L. Other routine blood tests including blood cell count, liver function tests and creatinine were normal as was the chest x-ray. A purified protein derivate (PPD) skin test was 17 mm, indicating TB-exposure. A CT scan of the chest and abdomen didnt show any conclusive pathological findings, therefore an 18-fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) was performed. This revealed inflammation in a few small abdominal lymph nodes, but more remarkable; a clearly illuminating mass was found in the lateral wall of the right cardiac atrium (Fig. 1). Transthoracic echocardiogram confirmed a 30 x 15 mm mass without any hemodynamic influence. At this point, an active abdominal tuberculosis infection was suspected with the intracardiac mass possibly caused by myxoma, sarcoma or tuberculoma. The abdominal lymph nodes were not accessible for biopsy, without performing a laparotomy.
To take biopsy for culture was important, in part due to previous TB treatment and the consequent risk of resistance. She was therefore referred to another hospital for a diagnostic percutaneous femoral vascular catheter guided biopsy of the right atrial mass. The biopsy itself was successful. By mistake the sample was placed in formaldehyde, with subsequently negative TB culture. Also PCR to detect Mycobacterium tuberculosis was negative. Histopathological examination of the sample showed myxoid tissue but also epitheloid cell granuloma, where the latter could indicate tuberculosis among other types of chronic inflammation. Acid-fast stain was negative. At that stage, myxoma was primarily suspected, and open surgical resection was planned.
The patient was informed by thoracic surgeons and was strongly recommended for operation. However, she declined operation because she had spontaneously improved and she discharged herself from hospital. She had no contact with health care services for about half a year. Induced sputum cultures as well as urine and faecal cultures were later found negative regarding TB. Six months later she was motivated for surgery follow several episodes of atrial fibrillation causing chest pain but no signs of uncompensated heart failure.
At the operation, via median sternotomy, a tumorous mass with macroscopically malignant appearance was seen in the right atrial wall. The surgeons decided to excise around 75% of the mass avoiding radical excision to prevent causing permanent tricuspid valve insufficiency (Fig. 2).
Histopathological examination of the specimen revealed granulomatous inflammation including epitheliod cell granuloma, multinucleated giant cells and small necrotic areas, but no signs of malignancy. Acid-fast stain and PCR for M. tuberculosis were negative. Four weeks later, the TB culture showed growth of a fully sensitive strain, and TB treatment was started with isoniazid, rifampicin and pyrazinamide in recommended dosage.
Shortly after confirmation of the TB diagnosis a minor wound infection was found in the proximal end of the median sternotomy. An ordinary wound culture was negative. At the same time, an abscess measuring 2.5 cm in diameter developed in the abdominal wall musculature involving costal cartilage. Culture from the operation wound and the abscess were both positive for M. tuberculosis. Thus the diagnosis was active multifocal TB with verified cultures from intracardiac tuberculoma, sternotomy wound and abdominal wall abscess, and with suspected involvement of abdominal lymph nodes.
After two months treatment, inflammatory parameters were normalized which in combination with good clinical response prompted the decision to terminate treatment after 9 months. The decision was supported by a FDG-PET/CT which showed distinct regression of right atrial wall inflammation.
At follow-up, ten months after completion of treatment, the patient was fully recovered with normal inflammatory parameters and without any signs of relapse clinically or on a chest CT scan.