Hekim KARAPINAR, İrfan BARUTÇU, Osman KARAKAYA, Cihangir KAYMAZ, Mustafa SAĞLAM

Yaşlı bir hastada sağ atriyumu tutan tüberkülom

Tüberkülom, intrakardiyak kitlelerin ayırıcı tanısında düşünülmesi gereken nadir bir durumdur. Otuz beş yıl önce akciğer tüberkülozu nedeniyle tedavi gören 74 yaşında kadın hasta nefes darlığı ve epigastrik ağrı yakınmalarıyla başvurdu. Ayrıca, altı ay önce ileri atriyoventriküler blok nedeniyle hastaya VVIR kalıcı kalp pili takılmıştı. Transtorasik ve transözofageal ekokardiyografide sağ atriyumda trombüs düşündüren kitle görülmesi üzerine antikoagülan tedaviye başlandı. Ekokardiyografi bulgularının antikoagülasyonun sekizinci gününde de devam etmesi üzerine, sağ atriyumu dolduran kitle ameliyatla çıkarıldı. Kitlenin patolojik incelemesinde kazeifikasyon nekrozu saptandı ve hastada dörtlü antitüberküloz tedaviye başlandı. Ameliyattan iki hafta sonra taburcu edilen hasta genel durumunun kötüleşmesi üzerine tekrar yatırıldı ve solunum yetersizliği nedeniyle entübe edilerek ventilatöre bağlandı. Entübasyonun beşinci gününde hasta septik şok nedeniyle kaybedildi.

Tuberculoma invading the right atrium in an old patient

Tuberculoma is a rare condition which is considered in the differential diagnosis of intracardiac masses. A 74-year-old woman presented with complaints of dyspnea and epigastric pain. She had a history of pulmonary tuberculosis treated 35 years before and VVIR permanent pacemaker implantation for severe atrioventricular block six months before. Transthoracic and transesophageal echocardiography showed a right atrial mass suggestive of thrombus and anticoagulant therapy was instituted. However, echocardiographic findings persisted on the eighth day of anticoagulation and the mass filling the right atrium was removed surgically. Pathologic examination of the surgical specimen showed caseous necrosis and the patient was administered antituberculous treatment with four drugs. She was discharged two weeks postoperatively, but was hospitalized again because of deterioration of her general status and respiratory insufficiency, requiring intubation and ventilation. She died on the fifth day of intubation from septic shock.

PDF

___

1) Wren C, Stovin PG. Isolated interventricular septal tuberculoma causing complete heart block. Thorax 1982;37:149-50.
2) Horn H, Saphir O. The involvement of myocardium in tuberculosis: a review of literature and a report of three cases. Am Rev Tuber 1935;32:492-504.
3) Kapoor OP, Mascarenhas E, Rananaware MM, Gadgil RK. Tuberculoma of the heart. Report of 9 cases. Am Heart J 1973;86:334-40.
4) Behr G, Palin HC, Temperly JM. Myocardial tuberculosis. Br Med J 1977;1:951.
5) Rawls WJ, Shuford WH, Logan WD, Hurst JW, Schlant RC. Right ventricular outflow tract obstruction produced by a myocardial abscess in a patient with tuberculosis. Am J Cardiol 1968;21:738-45.
6) Halim MA, Mercer EN, Guinn GA. Myocardial tuberculoma with rupture and pseudoaneurysm formation-successful surgical treatment. Br Heart J 1985;54:603 4.
7) Soyer R, Brunet A, Chevallier B, Leroy J, Morere M, Redonnet M. Tuberculous aortic insufficiency. Report of a case with successful surgical treatment. J Thorac Cardiovasc Surg 1981; 82:254-6.
8) Gaultier Y, Alou A, Cenac A, Develoux M, Vetter JM. Tuberculoma of the heart. Contribution of echography. Apropos of a case. Arch Mal Coeur Vaiss 1987;80:1413-6. [Abstract]
9) Ozer N, Aytemir K, Sade E, Oto A, Aksoy S, Engin H, et al. Cardiac tuberculosis with multiple intracardiac masses: a case report. J Am Soc Echocardiogr 2002;15:756-8.
10) Jagia P, Gulati GS, Sharma S, Goyal NK, Gaikwad S, Saxena A. MRI features of tuberculoma of the right atrial myocardium. Pediatr Radiol 2004;34:904-7.
11) Liu PY, Tsai WC, Chen JH, Kan CD, Yan JJ. Coexistence of tuberculous constrictive pericarditis and right atrial tuberculoma: a case report. J Formos Med Assoc 2001;100:336-8.
12) Chang BC, Ha JW, Kim JT, Chung N, Cho SH. Intracardiac tuberculoma. Ann Thorac Surg 1999;67:226-8.