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Invasive Cardiac Aspergillosis With Postinfectious Left Ventricular Aneurysm in a Patient With Acute Myeloid Leukemia
Canadian Journal of Cardiology 30 (2014) 1463.e1e1463.e2 www.onlinecjc.ca
Images in Cardiology
Invasive Cardiac Aspergillosis With Postinfectious Left Ventricular Aneurysm in a Patient With Acute Myeloid Leukemia Stefan Baumann, MD,a,b Matthias Renker, MD,a,c U. Joseph Schoepf, MD,a Pal Suranyi, MD, PhD,a Brett S. Harris, PhD,a and Akos Varga-Szemes, MD, PhDa a
Heart and Vascular Center, Medical University of South Carolina, Charleston, South Carolina, USA b c
First Department of Medicine, University Medical Centre Mannheim, Mannheim, Germany
Department of Internal Medicine I, Cardiology/Angiology, Giessen University, Giessen, Germany
A 48-year-old woman with acute myeloid leukemia and severe neutropenia was admitted with nonproductive cough and fever. Chest radiography suggested left lower lobe (LLL) pneumonia (Fig. 1A). Echocardiography showed a mass of uncertain cause abutting the left ventricle (Supplemental Fig. S1A). Chest computed tomography revealed pulmonary ground-glass opacity involving the left upper lobe and cavitation in the LLL. Abdominal computed tomography showed hypoattenuating liver lesions, and subsequent biopsy results showed hepatic necrosis with fungal elements (Aspergillus fumigatus). Observation of the lower thorax revealed a possible left ventricular (LV) thrombus (Supplemental Fig. S1B). After 6 months, coronary computed tomographic angiography showed shrinkage of the LLL cavity (Fig. 1B, star), a postinfectious LV aneurysm (Fig. 1B and Supplemental Fig. S1C), and patent coronary arteries (Supplemental Fig. S1D). Cardiac magnetic resonance imaging detected a mural thrombus in the LV aneurysm (Fig. 1, C and D) and showed mediastinal invasion of the LLL mass (Supplemental , view videos online). Fig. 1, E and F; Videos 1 and 2 Thinning and delayed enhancement of the lateral LV wall (Fig. 1D) suggested infectious myocardial involvement. Based on magnetic resonance imaging findings, the absence of coronary artery disease, and the proximity to the lung abscess, a diagnosis of infectious myocarditis from direct extension was the most likely cause of the aneurysm. Unfortunately, the patient died because of the severe course of her disease.
Received for publication May 15, 2014. Accepted June 24, 2014. Corresponding author: Dr U. Joseph Schoepf, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, South Carolina 29425-2260, USA. Tel.: þ1-843-792-2633; fax: þ1-843-792-0409. E-mail: [email protected] See page 1463.e1 for disclosure information.
Most frequently, LV aneurysms are a result of myocardial infarction or cardiac surgery and only rarely of infectious causes such as Chagas disease, Behçet syndrome, tuberculosis, or human immunodeficiency virus.1 Invasive aspergillosis of the heart may present as an intracavitary mass, myocardial abscess, valvular endocarditis, or embolization of Aspergillus into the coronary arteries.2 The timely diagnosis by multimodality imaging is critical for the early initiation of antifungal treatment. Unique to this case are the dimensions of the large infectious mass with cardiac involvement by invasive aspergillosis with extensive multimodality imaging workup.
Disclosures UJS is a consultant for and receives research support from Bayer, Bracco, GE Healthcare, Medrad, and Siemens Healthcare. The authors have no conflicts of interest to disclose. References 1. Paul M, Schafers M, Grude M, et al. Idiopathic left ventricular aneurysm and sudden cardiac death in young adults. Europace 2006;8:607-12. 2. Paul M, Schuster A, Hussain ST, Nagel E, Chiribiri A. Invasive aspergillosis: extensive cardiac involvement demonstrated by cardiac magnetic resonance. Circulation 2012;126:1780-3.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.06.017.
http://dx.doi.org/10.1016/j.cjca.2014.06.017 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1463.e2
Canadian Journal of Cardiology Volume 30 2014
Figure 1. (A) Chest radiograph on admission. (B) Chest computed tomographic scan shows left lower lobe (LLL) cavity (star) and left ventricular (LV) aneurysm (arrow) of the free wall. (C) Early postcontrast cardiac magnetic resonance (CMR) image shows mural thrombus in the aneurysm (arrow). (D) Delayed-enhancement CMR shows enhancement in the lateral LV wall (white arrows) and mural thrombus (black arrow) adjacent to the lung cavity (star).
Images in Cardiology
Invasive Cardiac Aspergillosis With Postinfectious Left Ventricular Aneurysm in a Patient With Acute Myeloid Leukemia Stefan Baumann, MD,a,b Matthias Renker, MD,a,c U. Joseph Schoepf, MD,a Pal Suranyi, MD, PhD,a Brett S. Harris, PhD,a and Akos Varga-Szemes, MD, PhDa a
Heart and Vascular Center, Medical University of South Carolina, Charleston, South Carolina, USA b c
First Department of Medicine, University Medical Centre Mannheim, Mannheim, Germany
Department of Internal Medicine I, Cardiology/Angiology, Giessen University, Giessen, Germany
A 48-year-old woman with acute myeloid leukemia and severe neutropenia was admitted with nonproductive cough and fever. Chest radiography suggested left lower lobe (LLL) pneumonia (Fig. 1A). Echocardiography showed a mass of uncertain cause abutting the left ventricle (Supplemental Fig. S1A). Chest computed tomography revealed pulmonary ground-glass opacity involving the left upper lobe and cavitation in the LLL. Abdominal computed tomography showed hypoattenuating liver lesions, and subsequent biopsy results showed hepatic necrosis with fungal elements (Aspergillus fumigatus). Observation of the lower thorax revealed a possible left ventricular (LV) thrombus (Supplemental Fig. S1B). After 6 months, coronary computed tomographic angiography showed shrinkage of the LLL cavity (Fig. 1B, star), a postinfectious LV aneurysm (Fig. 1B and Supplemental Fig. S1C), and patent coronary arteries (Supplemental Fig. S1D). Cardiac magnetic resonance imaging detected a mural thrombus in the LV aneurysm (Fig. 1, C and D) and showed mediastinal invasion of the LLL mass (Supplemental , view videos online). Fig. 1, E and F; Videos 1 and 2 Thinning and delayed enhancement of the lateral LV wall (Fig. 1D) suggested infectious myocardial involvement. Based on magnetic resonance imaging findings, the absence of coronary artery disease, and the proximity to the lung abscess, a diagnosis of infectious myocarditis from direct extension was the most likely cause of the aneurysm. Unfortunately, the patient died because of the severe course of her disease.
Received for publication May 15, 2014. Accepted June 24, 2014. Corresponding author: Dr U. Joseph Schoepf, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, South Carolina 29425-2260, USA. Tel.: þ1-843-792-2633; fax: þ1-843-792-0409. E-mail: [email protected] See page 1463.e1 for disclosure information.
Most frequently, LV aneurysms are a result of myocardial infarction or cardiac surgery and only rarely of infectious causes such as Chagas disease, Behçet syndrome, tuberculosis, or human immunodeficiency virus.1 Invasive aspergillosis of the heart may present as an intracavitary mass, myocardial abscess, valvular endocarditis, or embolization of Aspergillus into the coronary arteries.2 The timely diagnosis by multimodality imaging is critical for the early initiation of antifungal treatment. Unique to this case are the dimensions of the large infectious mass with cardiac involvement by invasive aspergillosis with extensive multimodality imaging workup.
Disclosures UJS is a consultant for and receives research support from Bayer, Bracco, GE Healthcare, Medrad, and Siemens Healthcare. The authors have no conflicts of interest to disclose. References 1. Paul M, Schafers M, Grude M, et al. Idiopathic left ventricular aneurysm and sudden cardiac death in young adults. Europace 2006;8:607-12. 2. Paul M, Schuster A, Hussain ST, Nagel E, Chiribiri A. Invasive aspergillosis: extensive cardiac involvement demonstrated by cardiac magnetic resonance. Circulation 2012;126:1780-3.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.06.017.
http://dx.doi.org/10.1016/j.cjca.2014.06.017 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1463.e2
Canadian Journal of Cardiology Volume 30 2014
Figure 1. (A) Chest radiograph on admission. (B) Chest computed tomographic scan shows left lower lobe (LLL) cavity (star) and left ventricular (LV) aneurysm (arrow) of the free wall. (C) Early postcontrast cardiac magnetic resonance (CMR) image shows mural thrombus in the aneurysm (arrow). (D) Delayed-enhancement CMR shows enhancement in the lateral LV wall (white arrows) and mural thrombus (black arrow) adjacent to the lung cavity (star).