Chest
Pulmonary and Critical Care PearlsFever and Night Sweats in a 22-Year-Old Man With a Mediastinal Mass Involving the Heart*
Section snippets
Physical Examination
On hospital admission, the patient’s temperature was 37.3°C, pulse was regular, heart rate was 162 beats/min, BP was 126/88 mm Hg, and transcutaneous oxygen saturation was 94%. The respiratory rate was normal, but breath sounds were diminished in the lower parts of the left lung, and a few crackles were heard bilaterally. Auscultation of the heart was normal. The neck veins were not distended, and no peripheral edema, clubbing, or cyanosis was present. The abdomen was soft with tenderness over
Laboratory and Radiographic Findings
Normocytic, normochromic anemia (hemoglobin, 117 g/L), a leukocytosis of 14.6 × 103/μL, and a slightly elevated platelet count (335 × 103/μL) were detected. Erythrocyte sedimentation rate was 105 mm/h. Serum electrolytes, glucose, and creatinine levels were normal. Alkaline phosphatase was minimally elevated (380 U/L), and γ-glutamyl transpeptidase was clearly increased (141 U/L). C-reactive protein was slightly elevated (41 mg/L). Hypoalbuminemia (29.9 g/L) was present with an elevation of the
Clinical Course
Because malignant lymphoma of the mediastinum with threatening obstruction of the vena cava was suspected, treatment with prednisone and allopurinol was started immediately. By IV administration of amiodarone, atrial flutter was converted to sinus rhythm.
CT-guided transcutaneous aspiration of the mediastinal masses revealed necrotic material and was not diagnostic. Values for α-fetoprotein and β-human chorionic gonadotropin were normal. HIV antibodies were not detected. Transthoracic
Diagnosis: Pulmonary and mediastinal tuberculosis with tuberculoma of the heart
Presentation of tuberculosis as a mediastinal mass is an unusual but well-known feature, especially in immunocompromised persons. However, the differential diagnosis of masses of the anterior and mid-mediastinum includes thymomas, lymphomas, teratomatous neoplasms, thyroid masses, vascular masses, lymph node enlargement due to metastases or granulomatous disease, and pleuropericardial and bronchogenic cysts. In Western societies, thymoma is the most common primary tumor, usually surrounded by a
Clinical Pearls
1. Presentation of tuberculosis as a mediastinal mass is an unusual but well-known feature, especially in immunocompromised persons.
2. Mediastinal tuberculosis may infiltrate and invade the heart and form an intracardiac mass with central caseation, called tuberculoma of the heart.
3. Atrial flutter and atrial fibrillation are characteristic manifestations of cardiac tuberculosis, especially if infiltration of the atria is present.
4. Cardiac tuberculoma may completely resolve after standard
References (0)
Cited by (20)
Pancardiac tuberculosis — a case report
2016, Cardiovascular PathologyCitation Excerpt :Pericardium is commonly involved by tuberculosis due to retrograde lymphatic spread from peritracheal, peribronchial, and mediastinal lymph nodes or by hematogenous spread. Tuberculous pericarditis accounts for 69.5% of cases in developing countries, whereas only 4% of cases in developed countries [1]. Myocardial involvement by tuberculosis is mostly seen in association with pericardial disease.
Two cases of culture proven Mycobacterium tuberculosis presenting with a broad-complex tachycardia and non-caseating granulomas
2014, Respiratory Medicine Case ReportsCitation Excerpt :It is proposed that TB myocarditis arises from three possible routes of spread: direct infection from the pericardium, haematogenous seeding, or through lymphatic spread. The case report by Khurana et al., 2007, in agreement with Maeder et al., 2003 [8] suggests that there may be an anatomical predilection to the right-sided mediastinal lymph nodes “making the right side of the heart the most vulnerable area of the myocardium owing to the potential for direct spread” [9]. Further investigation is necessary to determine whether this is a true association or coincidental.
Unusual location of tuberculosis: Three case reports
2009, Revue de Medecine InterneA 23 year-old man with cardiac tamponade
2004, Medicina ClinicaRare case of cystic anterior mediastinal tuberculosis in an immunocompetent patient
2022, Respirology Case Reports