Image in cardiology
Diagnostic dilemma: Intracardiac mass in a woman with Behçet's syndrome
Dilema diagnóstico: masa intracardiaca en una paciente con síndrome de Behçet
Edilberto Núñez-Cabarcasa, Nilson López-Ruizb,
, Alex Ramírez-Rincónc
Corresponding author
nlopez@hptu.org.co
Corresponding author at: Calle 78B 69-240, Medellín, Colombia. Tel.: +57 4 4459000x9143; fax: +57 4 4411440.
Corresponding author at: Calle 78B 69-240, Medellín, Colombia. Tel.: +57 4 4459000x9143; fax: +57 4 4411440.
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Tel.: +57 4 4459000x9143; fax: +57 4 4411440." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dilema diagnóstico: masa intracardiaca en una paciente con síndrome de Behçet" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1729 "Ancho" => 2309 "Tamanyo" => 272235 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Two-dimensional echocardiography: parasternal short axis view showing a mass (asterisk) on the posterior wall of the right atrium (RA). (B) Three-dimensional echocardiography: right ventricle (RV) inflow tract view displaying a round shaped mass (asterisk) with a stalk attached to the posterior wall of the RA. (C) Delayed-enhancement cardiovascular magnetic resonance demonstrating the lack of gadolinium contrast uptake (asterisk) as the thombus is avascular. (D) Three-dimensional echocardiography: normal RV inflow tract view without evidence of thrombus after sixth months of anticoagulation therapy. LA: left atrium.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 51 year-old woman with Behçet's syndrome developed a spontaneous <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteremia and prolonged fever, which prompted us to perform an echocardiogram in order to rule out infectious endocarditis. No valvular or mural vegetations were noticed on transthoracic (2D and 3D images) or transesophageal echocardiography. However, a round shaped mobile mass with a stalk attached to the posterior wall of the right atrium (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B) was evident, and raised the possibility of a cardiac tumor. But, as another filiform mobile image was visible in the superior vena cava (not shown), such possibility was questioned, and the patient was anticoagulated and underwent a cardiac magnetic resonance imaging (CMR) for characterizing the pseudotumor. The pregadolinium gradient echo-CMR revealed low signal intensity in the tumor and the contrast-enhanced scan showed lack of enhancement of the tumor mass (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) favoring the diagnosis of a thrombus. Concurrently, a computed pulmonary angiography ruled out both embolism and aneurisms. The fever subsided and the patient's status improved over the days, and then she was discharged on anticoagulant therapy with warfarin. On a new transthoracic echocardiogram, performed 6 months later (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D), there was no evidence of the thrombus previously seen in the right atrium, so warfarin was withheld. She has remained stable one year later without symptoms of thrombus recurrence.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In one of the largest case series published so far, 52 (6%) patients from a cohort of 807 patients with Behçet's disease (BD) had some form of cardiac involvement including pericarditis, endocarditis, myocardial infarction, endomyocardial fibrosis, and aneurysms of the coronary arteries of sinus of Valsalva.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, intracardiac thrombosis is a rare finding with only 32 cases reported in the medical literature.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In an analysis of 25 patients, 56% of them had clinical manifestations like fever, hemoptysis, dyspnea, and cough.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cardiac thrombi affected most often the right side (right ventricle, 52%; right atrium, 24%) and were unusual in the left or both chambers (4 and 16% of cases, respectively). Besides, intracardiac thrombi were also associated with thrombosis of the vena cava and pulmonary embolism (28 and 60% of cases, respectively).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The echocardiographic appearance of thrombi may suggest a tumor, and several patients have undergone cardiac surgery but histological examination demonstrated thrombi in all cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> CMR is a useful technique for the differential diagnosis between cardiac thrombus and tumor and might be helpful in difficult cases like the one presented here.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There is no consensus about the optimal treatment of intracardiac thrombosis in BD. Most patients receive immunosuppressive therapy (usually steroids in combination with azathioprine or cyclophosphamide) along with anticoagulation but some have reported the thrombi resolution only with immunosuppression particularly when hemoptysis or pulmonary artery aneurysms preclude the use of anticoagulants.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> Complete remission of intracardiac thrombosis has occurred in 75% of cases with corticosteroids and anticoagulation. Even though surgical resection seems an option when thrombi persist despite optimal medical therapy,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the risk of recurrence and death is an issue.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> Finally, although the 5-year survival rate is lower in BD patients with heart involvement (84% vs. 96% in patients without cardiac lesions),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the type of affectation is heterogeneous and prognosis differs accordingly. Notwithstanding, except for the risk of pulmonary embolism, the long-term prognosis of BD patients with intracardiac thrombi seems to be good as long as they receive only medical management.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0015" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "xres389768" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec368042" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres389767" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec368043" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-01-27" "fechaAceptado" => "2014-03-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec368042" "palabras" => array:6 [ 0 => "Behçet syndrome" 1 => "Heart diseases" 2 => "Thrombosis" 3 => "Echocardiography" 4 => "Magnetic resonance imaging" 5 => "Colombia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec368043" "palabras" => array:6 [ 0 => "Síndrome de Behçet" 1 => "Cardiopatías" 2 => "Trombosis" 3 => "Ecocardiografía" 4 => "Imagen por resonancia magnética" 5 => "Colombia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intracardiac thrombosis is a rare manifestation of cardiac involvement in Behçet's disease, and it may be mistaken for a heart tumor. In this letter we present the case of a patient diagnosed with Behçet's disease who was incidentally found to have a mass in the right atrium suspicious of a cardiac tumor. Nevertheless, cardiac magnetic resonance showed a cardiac thrombus. Immunosuppressive therapy and anticoagulation were effective for thrombus resolution.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La trombosis intracardiaca es una manifestación muy rara del compromiso cardiaco en la enfermedad de Behçet, la cual puede confundirse con una masa tumoral. Se presenta el caso de una paciente con esta enfermedad a quien de manera incidental se le detectó una masa intraauricular derecha sugestiva de tumor intracardiaco. Sin embargo los hallazgos de la resonancia magnética cardiaca fueron los de un trombo intracavitario que se resolvió con tratamiento inmunosupresor y terapia anticoagulante.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1729 "Ancho" => 2309 "Tamanyo" => 272235 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Two-dimensional echocardiography: parasternal short axis view showing a mass (asterisk) on the posterior wall of the right atrium (RA). (B) Three-dimensional echocardiography: right ventricle (RV) inflow tract view displaying a round shaped mass (asterisk) with a stalk attached to the posterior wall of the RA. (C) Delayed-enhancement cardiovascular magnetic resonance demonstrating the lack of gadolinium contrast uptake (asterisk) as the thombus is avascular. (D) Three-dimensional echocardiography: normal RV inflow tract view without evidence of thrombus after sixth months of anticoagulation therapy. LA: left atrium.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spectrum of cardiac lesions in Behçet disease: a series of 52 patients and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Geri" 1 => "B. Wechsler" 2 => "D.L. Thi Huong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2012" "volumen" => "91" "paginaInicial" => "25" "paginaFinal" => "34" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intracardiac thrombus in Behçet's disease: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Mogulkoc" 1 => "M.I. Burgess" 2 => "P.W. Bishop" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2000" "volumen" => "118" "paginaInicial" => "479" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10936144" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Magnetic resonance imaging of cardiac tumors: Part 2, malignant tumors and tumor-like conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Randhawa" 1 => "A. Ganeshan" 2 => "E.T.D. Hoey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/j.cpradiol.2010.07.002" "Revista" => array:6 [ "tituloSerie" => "Curr Probl Diagn Radiol" "fecha" => "2011" "volumen" => "40" "paginaInicial" => "169" "paginaFinal" => "179" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21616279" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resolution of intracardiac and pulmonary thrombi without anticoagulation in a patient with Behçet's disease: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.M. Samrah" 1 => "S.S. Saadeh" 2 => "K.M. Alawneh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Clin Exp Rheumatol" "fecha" => "2013" "volumen" => "31" "numero" => "3 Suppl. 77" "paginaInicial" => "90" "paginaFinal" => "92" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23463899" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A recurrent right atrial thrombus: a suggestive sign for Behçet's disease? A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.B. Altunkeser" 1 => "N. Görmüş" 2 => "K. Ozdemir" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s003800200021" "Revista" => array:6 [ "tituloSerie" => "Heart Vessels" "fecha" => "2002" "volumen" => "16" "paginaInicial" => "196" "paginaFinal" => "197" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12181593" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/14059940/0000008400000004/v1_201412120156/S140599401400127X/v1_201412120156/en/main.assets" "Apartado" => array:4 [ "identificador" => "9820" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Imagen en Cardiología" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/14059940/0000008400000004/v1_201412120156/S140599401400127X/v1_201412120156/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S140599401400127X?idApp=UINPBA00004N" ]
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| 2023 August | 26 | 2 | 28 |
| 2023 July | 22 | 5 | 27 |
| 2023 June | 16 | 2 | 18 |
| 2023 May | 67 | 4 | 71 |
| 2023 April | 82 | 0 | 82 |
| 2023 March | 39 | 1 | 40 |
| 2023 February | 22 | 4 | 26 |
| 2023 January | 18 | 4 | 22 |
| 2022 December | 15 | 4 | 19 |
| 2022 November | 24 | 11 | 35 |
| 2022 October | 22 | 12 | 34 |
| 2022 September | 19 | 5 | 24 |
| 2022 August | 31 | 8 | 39 |
| 2022 July | 30 | 8 | 38 |
| 2022 June | 17 | 4 | 21 |
| 2022 May | 17 | 6 | 23 |
| 2022 April | 27 | 10 | 37 |
| 2022 March | 22 | 11 | 33 |
| 2022 February | 21 | 8 | 29 |
| 2022 January | 18 | 5 | 23 |
| 2021 December | 24 | 8 | 32 |
| 2021 November | 36 | 10 | 46 |
| 2021 October | 72 | 16 | 88 |
| 2021 September | 40 | 15 | 55 |
| 2021 August | 49 | 8 | 57 |
| 2021 July | 29 | 8 | 37 |
| 2021 June | 16 | 8 | 24 |
| 2021 May | 22 | 5 | 27 |
| 2021 April | 63 | 18 | 81 |
| 2021 March | 27 | 7 | 34 |
| 2021 February | 15 | 3 | 18 |
| 2021 January | 13 | 10 | 23 |
| 2020 December | 14 | 3 | 17 |
| 2020 November | 13 | 6 | 19 |
| 2020 October | 15 | 11 | 26 |
| 2020 September | 9 | 9 | 18 |
| 2020 August | 15 | 1 | 16 |
| 2020 July | 16 | 5 | 21 |
| 2020 June | 7 | 4 | 11 |
| 2020 May | 12 | 6 | 18 |
| 2020 April | 10 | 5 | 15 |
| 2020 March | 11 | 0 | 11 |
| 2020 February | 7 | 6 | 13 |
| 2020 January | 16 | 8 | 24 |
| 2019 December | 21 | 5 | 26 |
| 2019 November | 7 | 5 | 12 |
| 2019 October | 12 | 7 | 19 |
| 2019 September | 11 | 3 | 14 |
| 2019 August | 6 | 0 | 6 |
| 2019 July | 16 | 6 | 22 |
| 2019 June | 37 | 10 | 47 |
| 2019 May | 112 | 18 | 130 |
| 2019 April | 26 | 5 | 31 |
| 2019 March | 5 | 5 | 10 |
| 2019 February | 4 | 12 | 16 |
| 2019 January | 5 | 6 | 11 |
| 2018 December | 4 | 5 | 9 |
| 2018 November | 6 | 1 | 7 |
| 2018 October | 7 | 5 | 12 |
| 2018 September | 9 | 1 | 10 |
| 2018 August | 5 | 8 | 13 |
| 2018 July | 4 | 6 | 10 |
| 2018 June | 5 | 3 | 8 |
| 2018 May | 5 | 0 | 5 |
| 2018 April | 1 | 1 | 2 |
| 2018 March | 5 | 1 | 6 |
| 2018 February | 6 | 4 | 10 |
| 2018 January | 4 | 1 | 5 |
| 2017 December | 13 | 2 | 15 |
| 2017 November | 1 | 2 | 3 |
| 2017 October | 10 | 3 | 13 |
| 2017 September | 10 | 9 | 19 |
| 2017 August | 9 | 15 | 24 |
| 2017 July | 13 | 3 | 16 |
| 2017 June | 12 | 39 | 51 |
| 2017 May | 18 | 16 | 34 |
| 2017 April | 18 | 24 | 42 |
| 2017 March | 22 | 35 | 57 |
| 2017 February | 16 | 2 | 18 |
| 2017 January | 22 | 0 | 22 |
| 2016 December | 26 | 10 | 36 |
| 2016 November | 33 | 6 | 39 |
| 2016 October | 36 | 23 | 59 |
| 2016 September | 35 | 6 | 41 |
| 2016 August | 28 | 2 | 30 |
| 2016 July | 19 | 2 | 21 |
| 2016 June | 25 | 8 | 33 |
| 2016 May | 29 | 12 | 41 |
| 2016 April | 21 | 19 | 40 |
| 2016 March | 24 | 12 | 36 |
| 2016 February | 25 | 18 | 43 |
| 2016 January | 25 | 21 | 46 |
| 2015 December | 22 | 12 | 34 |
| 2015 November | 22 | 19 | 41 |
| 2015 October | 28 | 21 | 49 |
| 2015 September | 18 | 21 | 39 |
| 2015 August | 20 | 41 | 61 |
| 2015 July | 13 | 27 | 40 |
| 2015 June | 8 | 32 | 40 |
| 2015 May | 25 | 47 | 72 |
| 2015 April | 27 | 58 | 85 |
| 2015 March | 22 | 27 | 49 |
| 2015 February | 68 | 43 | 111 |
| 2015 January | 67 | 30 | 97 |
| 2014 December | 34 | 14 | 48 |
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