This is a young man who came with palpitations. An echocardiogram showed an abnormal LV and the thought was of arrhythmogenic right ventricular cardiomyopathy (ARVC) or inflammatory cardiomyopathy. A cardiac MRI was performed.
The cine images show the unusual morphology. The papillary muscles insert directly onto the “apex”. The RV wraps around the LV. There is fat infiltration of the “apex” – essentially the epicardial fat seems to invaginate into the LV. In our case, the CT scan images also show calcification of the papillary muscles.
This is a 23-years old man who presented with right sided tachycardia. A CT scan of the chest was performed that showed a mass involving the RV and RA with enlarged necrotic mediastinal and right internal mammary nodes (Fig. 1). This was interpreted as a mass of unknown etiology, but nothing much was done.
A week later, for some reason, a cardiac CT was performed that showed normal coronary arteries (Fig. 2).
Two weeks later, a cardiac MRI was done. This showed the mass well (Fig. 3, video 3) involving the RV and RA as well as the RA appendage and the adjacent AV groove with mediastinal and internal mammary nodes.
A provisional diagnosis of angiosarcoma was made and a PET/CT study was performed the next day to look for lesions that might help give a clue to the diagnosis or amenable for biopsy. The PET/CT showed the mass well (Fig. 4A), along with active internal mammary (Fig. 4B) and mediastinal (Fig. 4C) nodes and it was decided to perform a CT guided biopsy of the internal mammary node (Fig. 5), which was performed the next day.
The biopsy report was caseating granulomatous inflammation of possible tuberculous etiology and the GeneXpert showed absence of rifampicin resistance.
The most common entity that presents as an RV mass is angiosarcoma. TB of the heart typically simulates sarcoidosis and usually presents as a “granulomatous cardiomyopathy” with nodes and areas of enhancement within the LV. TB presenting as a mass like lesion is unusual. This case teaches us how TB is still the greatest masquerader of all.