case_images: PMC3085497_01
case_images: Twelve-lead ECG demonstrating a complete atrioventricular block.
case_images: CRIM2011-740928.001.jpg
case_images: PMC3085497_01_CRIM2011-740928.001.jpg
case_images: fig1
case_images: Electrocardiogram (Figure 1) revealed complete atrioventricular block associated with atrial tachycardia.
case_images: Apical two-dimensional four-chamber (a) echocardiogram showing marked thickening of the right ventricle (arrow), right atrium (empty arrow), interatrial septum (empty arrowhead), and basal to mid interventricular septum (arrowhead) associated with a pericardial effusion. Aortic valve short-axis view (b) demonstrating that the thickened tissue (asterisk) extends around the root of aorta. RA indicates right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; AV, aortic valve.
case_images: CRIM2011-740928.002.jpg
case_images: PMC3085497_01_CRIM2011-740928.002.jpg
case_images: fig2
case_images: Transthoracic echocardiography (Figure 2(a), see Movie 1 Supplementary Material available online at doi:10.1155/2011/740928) revealed extensive localized thickening of the right ventricle, right atrium, interatrial septum, and basal to mid interventricular septum associated with a pericardial effusion. The infiltration extended around the root of the pulmonary artery and aorta (Figure 2(b), Movie 2).
case_images: T2-weighted short inversion-time, inversion-recovery (STIR) breath hold pulse sequences ((a) and (b)) showing concentric thickening and oedema of the right ventricle. The infiltration (asterisk) extends around the root of the pulmonary artery. Four-chamber SSFP cine view (c) showing infiltration of the right ventricle (arrow), right atrium (empty arrow), interatrial septum (empty arrowhead), and basal to mid interventricular septum (arrowhead). Four-chamber first-pass T1-weighted multishot gradient-echo echo-planar sequence (d) shows partial hyperenhancement (arrow) of the right ventricle in support of an inflammatory process. Four-chamber (e) and short-axis (f) three-dimensional phase-sensitive inversion recovery sequences demonstrating widespread and heterogeneous enhancement (#) of the right atrium and ventricle. RA indicates right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; PV, pulmonary valve.
case_images: CRIM2011-740928.003.jpg
case_images: PMC3085497_01_CRIM2011-740928.003.jpg
case_images: fig3
case_images: Four-chamber (Figure 3(c), Movie 3), apical short-axis, and long-axis (Movie 4) cine images were performed using steady-state free precession (SSFP) cine sequences. Short-axis dark-blood T2-weighted (Figures 3(a) and 3(b)) sequences confirmed concentric thickening and oedema of the right ventricle. First-pass perfusion (Figure 3(d), Movie 5) showed enhancement of the right ventricular and interventricular septum infiltration consistent with an active inflammatory process. CMR (Figures 3(e) and 3(f)) sequences demonstrated widespread and heterogeneous enhancement of the right ventricle. Combined (18)F-fluoro-2-deoxyglucose positron emission tomography (FDG PET)/computed tomography (CT) was performed to look for primary malignant lesion (Figure 4) showing moderate FDG uptake involving mainly the right heart chambers of the heart.
case_images: FDG-PET in the transaxial plane shows moderate FDG uptake (arrows) involving mainly the right heart.
case_images: CRIM2011-740928.004.jpg
case_images: PMC3085497_01_CRIM2011-740928.004.jpg
case_images: fig4
case_images: CMR (Figures 3(e) and 3(f)) sequences demonstrated widespread and heterogeneous enhancement of the right ventricle. Combined (18)F-fluoro-2-deoxyglucose positron emission tomography (FDG PET)/computed tomography (CT) was performed to look for primary malignant lesion (Figure 4) showing moderate FDG uptake involving mainly the right heart chambers of the heart.
case_images: Low (a) and high (b) magnifications of hematoxylin-eosin-safron stained sections showing nodular cellular infiltrates with abundant fibrosis; immunohistochemistry revealing a prevalence of CD3-positive T lymphocytes (c) and some CD68-positive histiocytes (d).
case_images: CRIM2011-740928.005.jpg
case_images: PMC3085497_01_CRIM2011-740928.005.jpg
case_images: fig5
case_images: Hematoxylin-eosin-saffron stained sections of the tissue sample showed a granulomatous reaction consisting of nodular cellular infiltrates (histiocytes associated with lymphocytic elements) with an abundant fibrotic reaction (Figures 5(a) and 5(b)). Immunohistochemistry revealed a prevalence of T lymphocytes (CD3 positive; Figure 5(c)) mixed with B lymphocytes (CD20 positive), histiocytes (CD68 positive; Figure 5(d)) and a few plasma cells (CD138 positive).