Vanishing cardiac mass

Abstract

Introduction: Most cardiac masses are let of as tumors and subjected to invasive surgery.We report a case of invasive zygomycosis in an immunocompetent patient presenting as febrile illness with cardiac and abdominal mass. Prompt diagnosis and initiation of antifungal therapy lead to resolution of symptoms and regression of both cardiac and abdominal masses. Case report description: 42 year old male presented with atypical chest pain, dyspnea, fever, anorexia and weight loss for past 3 months. Past history was significant for receiving antitubercular treatment for similar symptoms and right pleural effusion.He was febrile (100.4 °F) with rest of examination normal. Echocardiogram showed thick atrial septum and a mass infiltrating both atria.Thoraco-abdominal contrast enhanced computed tomography (CECT) revealed cardiac and a necrotic abdominal mass with lung fields showing right lower lobe fibrosis. As abdominal part of the mass was most easily accessible, CT guided Fine Needle Aspiration Cytology (FNAC) was performed, which on Gomori methenamine silver (GMS) staining showed, infrequently septate, right angled branching thin walled hyphae, typical of zygomycosis. Blood cultures, serum aspergillus antibody, Galactomanan assay, HIV ELISA, and Nitro Blue Tetrazolium (NBT) test were negative. CD4+ count and immunoglobulin levels were normal. He was started on liposomal Amphotericin which was well tolerated. His clinical status improved with remission of fever, weight gain and follow-up CECT, echocardiogram showed regression of both cardiac and abdominal masses. He is now on weekly amphotericin therapy and is in complete remission. Discussion: Zygomycosis is opportunistic infection caused by Zygomycetes class of fungi infecting a broad group of population with 20% cases reported in healthy individuals.Invasive zygomycosis present as angioinvasive disease with thrombotic complications. Cardiac involvement is a rare manifestation which presents as severe heart failure and hemodynamic deterioration.To the best of our knowledge this is first case report of disseminated zygomycosis presenting as slow smouldering course in an healthy person.Prompt initiation of therapy lead to resolution of lesions and marked clinical improvement. Conclusions: Zygomycosis should be kept as a differential diagnosis of intracardiac mass in patients presenting with fever and constitutional symptoms.This case demonstrates the importance of exercising high index of suspicion and pursuing an aggressive diagnostic and therapeutic strategy in recognising a potentially curable entity, which otherwise would have been subjected to surgery.