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.
Axial CT scan shows a mass (red arrows) involving the RV and RA.
Axial CT scan shows the mass (red arrows) in the AV groove and involving the RA appendage. Note the enlarge right internal mammary node (blue arrow)
Axial CT scan shows enlarged necrotic mediastinal nodes (blue arrow)
A week later, for some reason, a cardiac CT was performed that showed normal coronary arteries (Fig. 2).
CT cardiac shows normal proximal coronary arteries
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.
Delayed hyperenhanced 4C view of the heart shows an enhancing mass (red arrows) involving the RV and RA
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.
PET/CT shows the RV and RA mass (red arrows).
PET/CT shows a necrotic enlarged right internal mammary node
PET/CT shows an active mediastinal node as well.
CT guided biopsy of the internal mammary node.
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.
