Imaging Pericardial Nocardiosis by Cardiac Magnetic Resonance

Abstract

A 72-year-old female renal transplant recipient was admitted with asthenia and low-grade fever. Two months earlier, she developed nodular pulmonary infiltrates (Figure 1), and microbiological examination of bronchoalveolar lavage fluid established the diagnosis of pulmonary nocardiosis. She had been taking ciprofloxacin and minocycline since that time. Physical examination was unremarkable, and the ECG revealed normal sinus rhythm with atrial bigeminy and no conduction abnormalities (Figure 2). Because of persistent fever, cerebral and thoracoabdominal computed tomography scans were performed and revealed multiple cystic lesions in the brain and mediastinum. Subcutaneous nodular lesions were also seen in the thoracoabdominal wall. Needle aspiration of one of the latter revealed gram-positive bacilli and grew Nocardia farcinica.On admission, transthoracic echocardiography showed large cystic hyperechogenic masses localized around the lateral left ventricular wall ( Figures 3A and 3B), without signs of compression. Cardiac magnetic resonance allowed tissue characterization. In addition to subcutaneous nodules, T1-and T2-weighted spin-echo short-axis images showed multiple circumscribed masses surrounding the left ventricle and impinging on the right atrium. These masses appeared isointense on T1-weighted images ( Figure 4A) and hyperintense on T2-weighted images (Figure 4 B) and thus were suggestive of noncirculating high-protein fluid content. Mild associated myocardial edema was suspected visually on