Immunocompromised patient with multiple cardiac masses
Amelia Carro; Lourdes Pérez; Maria Mutuberria; Teresa Gonzalez-Alujas
Hospital Universitario Valle de Hebron, Barcelona, Spain
Keywords: Lung Neoplasms; Pneumonectomy; Aspergillus fumigatus; Endocarditis, Bacterial; Embolism.
A 57-year-old-man presented with a 4-day history of general weakness, cough with blood-stained sputum, pleuritic chest pain and fever (38.5ºC). His medical history revealed a left-superior pulmonary lobectomy (due to an in situ carcinoma) six years before, and a recently developed myelodysplasic syndrome during current chemotherapy. On admission, he showed bicytopenia and right-sided pneumothorax (Figure 1A). Expanded microbiological studies demonstrated Aspergillus fumigatus growth on tracheal aspirate and two positive determinations of serum galactomannan antigen. A computed tomography scan confirmed the diagnosis of pulmonary aspergillosis (Figure 1B); antifungal treatment was administered (voriconazole, amphotericin B). The clinical course steadily worsened, with multiple cutaneous petechiae, intense headache, visual disturbances and other signs suggestive of a neurologic process. Cerebrospinal fluid was positive for galactomannan antigen, and a cranial magnetic resonance imaging (MRI) diagnosed multiple cerebral infarcts and endophthalmitis (Figure 1C). Transthoracic (Figure 1D) and transesophageal (Figure 1E) echocardiograms were performed in search of an embolic source, revealing the presence of a large left atrial mass, as well as several smaller ones attached to other cardiac structures (Figures D, E, F; arrows), highly suggestive of vegetations. Cardiac MRI showed similar findings (Figure 1F), with no late gadolinium enhancement on conventional or phase-sensitive inversion recovery sequences. With all these imaging features, cardiac masses were interpreted as vegetations, although, without histological confirmation, there is a possibility that they might correspond to thrombi. The patient met the criteria for invasive pulmonary aspergillosis with endocarditis and septic embolisms, an infrequent form of the disease. It is remarkable the strikingly unusual size and location of the vegetations, the absence of valvular or ventricular dysfunction, and the aggressive clinical course that finally led to the patient's death.
Conception and design of the research, Analysis and interpretation of the data: Carro A, Gonzalez-Alujas T; Acquisition of data: Carro A, Pérez L; Writing of the manuscript: Carro A; Critical revision of the manuscript for intellectual content: Carro A, Pérez L, Mutuberria M, Gonzalez-Alujas T
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Sources of Funding
There were no external funding sources for this study.
This study is not associated with any post-graduation program.
Manuscript received June 26, 2012, revised manuscript December 24, 2012, accepted January 02, 2013.
Publication in this collection
06 May 2013
Date of issue