SCMR 22nd Annual Scientific Sessions
Description of Clinical Presentation:
37-years old male who presented with palpitations , back pain and weight loss.
Diagnostic Techniques and Their Most Important Findings:
Contrast enhanced multi parametric MRI was performed on a 3T scanner for evaluation. T1/T2 mapping along with STIR was done as well.
This showed ill defined masses involving the right atrium, measuring 4.7 x 2.7 cm in maximum four chamber dimensions with another mass in the RV apex measuring 3.9 x 2.1 cm in maximum transverse dimensions, extending into the RVoT, . However there was no RVoT obstruction and the rest of the RV showed good contractility and thickening. The native T1 values of the masses measured 1224 ms whereas the natvie T2 value of the masses were raised measuring upto 85.5 ms. (Normal native T1 value is 1293 ms and T2 is < 50 ms for our population on our machine). Heterogeneous enhancement of these lesions was seen.Patchy but widespread pericardial thickening and enhancement was seen, best appreciated along the mid and apical lateral LV wall, with subtle epicardial enhancement as well.The upper dorsal spine showed abnormal signal with abnormal perivertebral soft tissue, with significant involvement of the D8 vertebral body, with a perivertebral abscess.
CT guided biopsy of the D8 osteolytic lesion was done and the biopsy report was caseating granulomatous inflammation of possible tuberculous etiology and the GeneXpert showed absence of rifampicin resistance.
Learning Points from this Case:
The most common entity that presents as an RV mass is angiosarcoma. Tuberculosis (TB) of the myocardium typically resembles sarcoidosis and usually presents as a “granulomatous cardiomyopathy” with nodes and areas of enhancement and inflammation in the LV. TB presenting as a tumefactive lesion is unusual. In this case there was infective spondylodiscitis as well in the dorsal spine along with pericardial involvement .
This case teaches us how TB is still the greatest masquerader of all. It must be remembered as an important differential in tumefactive myocardial lesions , especially in endemic countries. Multiparametric MR is an excellent tool for diagnosis in such cases as seen here.