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Tuberculosis (TB) is a global health problem, in which the majority of cases occur in population-dense developing countries. Despite advances in various diagnostic TB modalities, extrapulmonary TB remains a challenge due to complexities related to its diagnostic approach. Hereby, we present a rare case of endocarditis and spondylodiscitis associated with Mycobacterium tuberculosis (MTB). This case report highlighted the challenges faced in diagnosing blood culture-negative infective endocarditis (BCNIE). We also emphasized the importance of considering MTB as etiology of BCNIE, particularly in endemic TB areas.
RESUMO
Superior vena cava syndrome is a life-threatening condition. Typically, the clinical presentations are gradual; hence, the diagnosis is often delayed until critical compression or obstruction has occurred. Pericardial hematoma is a rare condition that could occur after cardiac surgery. An asymptomatic, 25-year-old female, who underwent surgical atrial septal defect closure 5 days ago, was sent for routine echocardiography examination before discharge. An intrapericardiac hematoma was detected at the right atrium's free wall without any intracardiac hemodynamic consequences. The patient was discharged and planned for monthly evaluation. During follow-up, the intrapericardiac hematoma was expanding. In the third month's follow-up, the patient complained of shortness of breath, headaches, and coughs. Echocardiography evaluation revealed enlarged pericardial hematoma, which compressed the right atrium and superior vena cava orifice, without echo' sign of cardiac tamponade. Computed tomography scan revealed superior vena cava compression by the pericardial hematoma and appearance of the collateral vessel. The patient was diagnosed with superior vena cava syndrome and sent for surgical evacuation. Pericardial hematoma after cardiac surgery should be evaluated meticulously. Chronic expanding hematoma could cause superior vena cava syndrome, which is fatal. Early diagnosis and appropriate treatment are essential in managing this condition.
RESUMO
BACKGROUND: Pericardial hematoma is blood accumulation in the pericardial space. Although rare, it could arise in various conditions, such as after cardiac surgery. Clinical diagnosis of pericardial hematoma is implausible; thus, cardiac imaging plays a pivotal role in identifying this condition. We presented a case of multiple pericardial hematomas, which was found as an incidental finding in post-cardiac surgery evaluation. We highlighted the diagnostic challenge and the key features of multi-modality cardiac imaging in pericardial hematoma evaluation. CASE PRESENTATION: An asymptomatic, 35-years old male, who underwent surgical closure of secundum atrial septal defect (ASD) one month ago, came for routine transthoracic echocardiography evaluation. An intrapericardiac hematoma was visualized at the right ventricle (RV) 's free wall side. Another mass with an indistinct border was visualized near the right atrium (RA). This mass was suspected as pericardial hematoma differential diagnosed with intracardiac thrombus. Cardiac computed tomography (CT) scan showed both masses have an attenuation of 30-40 HU; however, the mass's border at the RA side was still not clearly delineated. Mild superior vena cava (SVC) compression and multiple mediastinal lymphadenopathies were also detected. These findings are not typical for pericardial hematomas nor intracardiac thrombus; hence another additional differential diagnosis of pericardial neoplasm was considered. We pursued further cardiac imaging modalities because the patient refused to undergo an open biopsy. Single-photon emission computer tomography (SPECT)/CT with Technetium-99 m (Tc-99 m) macro-aggregated albumin (MAA) and Sestamibi showed filling defect without increased radioactivity, thus exclude the intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) reveals intrapericardial masses with low intensity of T1 signal and heterogeneously high intensity on T2 signal weighted imaged and no evidence of gadolinium enhancement, which concluded the diagnosis as subacute pericardial hematomas. During follow-up, the patient remains asymptomatic, and after six months, the pericardial hematomas were resolved. CONCLUSION: Pericardial hematoma should be considered as a cause of pericardial masses after cardiac surgery. When imaging findings are atypical, further multi-modality cardiac imaging must be pursued to establish the diagnosis. Careful and meticulous follow-up should be considered for an asymptomatic patient with stable hemodynamic.
