International Journal of Cardiology, 26 (1990) 240-241 Elsevier

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CARD10 10150

Echocardiographic demonstration of resolving intrapericardial mass in tuberculous pericardial effusion

Sharad Agrawal, S. Radhakrishnan and Nakul Sinha Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

(Received 29 June 1989; revision accepted 20 September 1989)

A patient with tuberculous pericardial effusion is described who presented with cardiac tamponade. Subsequent to pericardiocentesis, a large echodense intrapericardial mass was observed which disappeared completely with antitubercu- lous chemotherapy. The resolution of the mass suggests that it was a conglomeration of fibrinous exudates deposited in the pericardial cavity. Presence of such exudates should not be considered an indication for surgical intervention.

Key words: Tuberculosis; Pericardial effusion; Intrapericardial mass; Echocardiography

Introduction

Tuberculous pericardial effusion is not an uncom- mon entity. Echocardiographic demonstration of in- trapericardial abnormalities in these cases, however, has rarely been described. In 1984, Chia et al. [l] described probably the first case of tuberculous pericardial effu- sion associated with an echodense intrapericardial mass. They could not describe the effect of antituberculous chemotherapy on that mass owing to lack of repeat echocardiographic examination. We report a patient with tuberculous pericardial effusion with an intraperi- cardial mass which resolved with antituberculous chemotherapy.

Case Report

A 45-year-old male patient presented with progres- sively increasing breathlessness on exertion. heaviness of the upper abdomen and irregular fever for 6 weeks. There was no history of chest trauma. Clinical examina- tion revealed a heart rate of 112 beats/minute and blood pressure of 115/70 mm Hg, with a paradoxical pulse of 15 mm Hg, raised jugular venous pressure with

Correspondence to: S. Radhakrishnan, M.D., Dept. of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, PO box 375. Raebareli Road. Lucknow: 226 001,

India.

absent “Y” descent, and cardiomegaly with soft heart sounds. He also had marked hepatomegaly, bilateral oedema of the feet and clear lung fields on auscultation. The chest X-ray revealed cardiomegaly (cardiothoracic ratio 75%) calcified right hilar lymph nodes and fibrosis of the upper lobe of the left lung. The electrocardio- gram showed low voltage QRS complexes and non specific ST-T changes. Echocardiographic examination revealed normal chambers and valves and a large peri- cardial effusion with diastolic right atrial compression (Fig. 1). No intrapericardial mass was detected at that time. Since the patient was in cardiac tamponade, he was immediately subjected to pericardiocentesis and 400 ml of haemorrhagic fluid was removed. Examina- tion of the fluid revealed it to be exudative in nature, with predominant lymphocytosis (70%). The fluid stained positively for acid fast bacilli. There were no malignant cells. Repeat echocardiographic examination following pericardiocentesis showed a decrease in the echofree space anteriorly as well as posteriorly without any diastolic collapse of the right atrium. At this time, a large echodense mass was identified in the posterior pericardial space attached to the parietal pericardium (Fig. la). The patient was given antituberculous chemo- therapy (consisting of rifampicin, isoniazid and ethambutol). After four months therapy, there was marked clinical improvement. An X-ray of the chest no longer revealed any cardiomegaly and echocardio- graphic examination showed complete disappearance of both the intrapericardial mass and the pericardial effu- sion (Fig. 2).

0167-5273/90/$03.50 Q 1990 Elsevier Science Publishers B.V. (Biomedical Division)

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Fig. 1. Apical four-chamber view (a) showing large pericardial effusion with diastolic collapse of right atrium (arrows). Following pericardiocentesis (b), an intrapericardial mass (arrows) is seen.

Fig. 2. Apical four-chamber view showing complete disap-

pearance of the intrapericardial mass and effusion after four months of antituberculous chemotherapy.

Comments

Intrapericardial echodense masses may be seen in association with pericardial effusions of varied aetiolo- gies. Martin et al. [2] described band-like intrapericar- dial echoes in patients having tumours treated with anterior mediastinal irradiation, advanced renal failure, pneumococcal pneumonia, and traumatic haemoperi- cardium. Similar intrapericardial masses along with pericardial effusion have also been noted in patients with pericardial metastases [3] and in a child with

purulent pericarditis due to infection with Hemophilus

influenzae [4].

Intrapericardial abnormalities in association with tuberculous pericardial effusion were probably first de- scribed by Chia et al. [l]. They found linear frond-like intrapericardial echodense structures which showed un- dulating movements and were seen to conglomerate into a dense mass protruding into the pericardial cavity. The authors concluded that they represented fibrinous peri- carditis. They were unable precisely to describe the effect of antituberculous chemotherapy on these in- trapericardial structures because of their inability to perform a repeat echocardiographic examination. The resolution of these intrapericardial abnormalities fol- lowing antituberculous chemotherapy in our case sug- gests that they probably represent deposition of fibrinous exudates along the visceral and parietal layers of the serous pericardium. The complete disappearance of such a mass subsequent to chemotherapy suggests that such a therapeutic trial is mandatory prior to surgical intervention.

References

1 Chia BL, Choo M, Tan A, Ee B. Echocardiographic

abnormalities in tuberculous pericardial effusion. Am Heart

J 1984;107:1034-1035.

2 Martin RP, Bowden R, Filly K, Popp RL. Intrapericardial

abnormalities in patients with pericardial effusion. Circula-

tion 1980;61:568-572. 3 Chandraratna PAN, Aronow W. Detection of pericardial

metastases by cross sectional echocardiography. Circulation

1981;63:197-198. 4 Wolf WJ. Echocardiographic features of a purulent pericar-

dial peel. Am Heart J 1986;11:990-992.