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Probable intracardiac tuberculoma in an HIV positive woman

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A 50 year old Zambian woman presented in August 1997 with fever and breathlessness. Echocardiography showed a left pleural effusion and a small pericardial effusion. Pleural fluid was exudative and lymphocytic, highly suggestive of tuberculosis. Culture for acid fast bacilli was negative. A clinical diagnosis of tuberculosis was made and she was prescribed quadruple antituberculous treatment. She was seropositive for the human immunodeficiency virus (HIV) with a reduced CD4 lymphocyte count of 220 cells/μl.

There was a good clinical response to antituberculous treatment with resolution of fever and pleural effusion. Combination antiretroviral treatment was started in November 1997. Repeat echocardiography in December 1997 (below left) revealed a new 2 × 3 cm mass in the wall of the right atrium involving the base of the tricuspid valve. The position of the mass within the right atrial wall was confirmed by cardiac magnetic resonance imaging. The patient declined invasive tests and was managed conservatively. There was no clinical, haematological, or microbiological evidence to suggest additional opportunistic infections, Kaposi’s sarcoma, or lymphoma.

Repeat echocardiography in April 1998 (below right) revealed spontaneous resolution of the mass. We have been unable to find any similar cases in the literature in either HIV positive or negative individuals. Presentation with new intracranial tuberculomas during treatment followed by resolution is well documented. Although there is no biopsy of the intracardiac lesion the clinical response to empirical antituberculous treatment in the absence of other disease strongly suggests that this lesion was a cardiac tuberculoma.