Case Report: Extrapulmonary tuberculosis presenting as multiple caseous pericardial masses

Our plain-English summary of Case Report: Extrapulmonary tuberculosis presenting as multiple caseous pericardial masses, by J. Wang, R. Zhang, Z. Li, et al (Frontiers in Cardiovascular Medicine, 2025).

The study

• Authors: J. Wang, R. Zhang, Z. Li, H. Fang, W. Zhang
• Journal: Frontiers in Cardiovascular Medicine
• Published: 2025;12:1529400
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

The diagnosis of tuberculous pericarditis presenting as a hemorrhagic pericardial effusion is not difficult to make, but the presence of multiple pericardial masses in tuberculous pericarditis is uncommon. The article reports a 55-year-old Asian woman with a 10-day history of fever, chest tightness and shortness of breath. Laboratory investigations revealed an elevated C-reactive protein and erythrocyte sedimentation rate, and echocardiography showed a small amount of pericardial effusion associated with multiple pericardial caseous masses (up to approximately 2.4 cm × 6.9 cm) without pericardial constriction. Ten ml of bloody pericardial effusion was punctured and sent for pathology without malignant cells, and malignant mesothelioma was excluded in combination with PET-CT results. The diagnosis of extrapulmonary tuberculosis was finally confirmed by a positive Mantoux test and positive tuberculosis immunoreactivity, and the patient is now receiving standardized anti-tuberculosis treatment in a specialist hospital. Nowadays, the diagnosis of tuberculous pericarditis is not difficult, but the symptoms of a concomitant giant mass are rare, and its nature and treatment options (including drugs or surgery) are worth exploring.

© 2025 Wang, Zhang, Li, Fang and Zhang.

In plain English

This case report described one patient, a 55-year-old Asian woman seen at the Affiliated Hospital of Qingdao University in China. It did not concern asbestos exposure. Malignant mesothelioma came up only as a possible diagnosis that the doctors tried to rule out. She had fever and cough, and scans showed fluid around the heart and around both lungs. Echocardiography found multiple masses in the sac around the heart, the largest about 2.4 by 6.9 cm. A PET-CT scan at first could not rule out malignant mesothelioma or infection. The authors later wrote that it showed no significant hypermetabolic foci. The 10 ml of fluid drawn from around the heart contained no malignant cells. A Mantoux skin test and a blood test for tuberculosis infection were positive. No pericardial biopsy was done. She received four anti-tuberculosis drugs and one month of prednisone. At follow-up the fluid around the lungs had gone and the masses had shrunk (about 1.4 by 6.6, compared with 2.4 by 6.9 before). The authors concluded that tuberculosis should be considered in patients with similar unexplained findings.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 55-year-old Asian woman with no history of chronic or infectious diseases, seen at the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China; dates of care not stated
• Exposure: Not an asbestos study; no asbestos or other occupational exposure is described. The condition reported was tuberculous infection of the pericardium (the sac around the heart).
• Main results:
  • Echocardiography in this patient showed a small pericardial effusion with multiple caseous pericardial masses, the largest approximately 2.4 cm by 6.9 cm, without pericardial constriction
  • PET-CT showed multiple left pericardial masses and bilateral pleural effusions; at that stage malignant mesothelioma or infectious pericarditis could not be excluded
  • In the discussion, the authors reported that PET-CT showed no significant hypermetabolic foci and that no malignant cells were found in the pericardial fluid
  • Pericardiocentesis removed 10 ml of non-coagulable fluid. It was not repeated because of the patient's pleural reaction, and the single sample showed no malignant cells
  • A Mantoux test and a blood T-cell test for tuberculosis infection were positive. The two interferon gamma release assay values were 0.37 and 0.55 IU/ml, against a reference range of less than 0.35
  • The patient was treated with rifampicin, isoniazid, pyrazinamide and ethambutol, plus prednisone for one month (starting at 20 mg, then tapered)
  • After treatment, the pleural effusion had disappeared and several pericardial masses had been resorbed: approximate range 1.4 by 6.6 compared with 2.4 by 6.9 before (units not stated). The figure is labelled as a 6-month follow-up echocardiogram
• The authors' conclusion: The authors concluded that in patients with these findings and an unknown diagnosis, tuberculosis should be considered so that anti-tuberculosis therapy can start promptly. In their view, delays may lead to chronic constrictive pericarditis or drug resistance.
• Limitations the authors state:
  • No pericardial biopsy was performed, so no histological proof was obtained. The diagnosis was ultimately supported by imaging changes after anti-tuberculosis treatment.
  • Only a single pericardial fluid sample was taken; a repeat puncture was not done because of the patient's pleural reaction

Topics

Medical terms in this study, explained in our Lexicon: Pericardial, Pericardial Effusion, Pathology, Mesothelioma, PET-CT.

Related studies

• Primary pericardial mesothelioma presenting as multiple pericardial masses on CT — M.C. Raeside, K. Gormly, et al. (2016)
• Pleural tuberculosis presented as multiple pleural masses: An atypical presentation — A. Patel, S. Choudhury (2013)
• Malignant mesothelioma with fungating masses and multiple sites involvement — J.K. Sim, J.Y. Oh, et al. (2017)
• Co-existing tuberculosis and malignant mesothelioma with multiple sites venous thrombosis: a case report — P. Kumar, K. Chawla, et al. (2016)
• Metastatic pleural mesothelioma presenting initially as multiple gastric and colonic polyps — A. Alhumidi, A. Alqahtani (2020)
• New nonsurgical technique for multiple pericardial biopsies — J. Endrys, M. Simo, et al. (1988)

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