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A 12 year old boy was admitted with supraventricular tachycardia and congestive heart failure. An echocardiogram showed dilatation of all four chambers of the heart with biventricular dysfunction, the left ventricular ejection fraction being 21%. In addition there was a large mass, occupying most of the right atrium, extending to the anterior and lateral wall but free of the interatrial septum and tricuspid valve (panel A). There was no restriction of flow to the right ventricle. Minimal pericardial effusion was present. Haematological, urine, and sputum examinations were normal. Computed tomography and magnetic resonance imaging were performed; however, the nature of the intracardiac mass could not be characterised further. Since the tissue diagnosis could not be made with these investigations, biopsy of the mass was performed using an endomyocardial bioptome. The histopathology revealed multiple, well formed necrotising epitheloid cell granulomas along with multinucleated giant cells with focal areas of necrosis, suggestive of a chronic inflammatory disease such as tuberculosis. The patient was treated with a diuretic, digoxin, and amiodarone to control the heart rate and the congestive heart failure. Based on endomyocardial biopsy findings and a wide prevalence of tuberculosis in this part of the world, antitubercular chemotherapy was added to his treatment. The patient was closely monitored and successive echocardiograms showed gradual resolution of the right atrial mass in six weeks. Treatment was continued for one year, and the last follow up echocardiogram showed near complete disappearance of the intracardiac mass (panel B). Left ventricular function improved with an ejection fraction of 45%.
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