ABC | Volume 110, Nº6, June 2018

Anatomopathological Correlation Arduine & Aiello Female patient with chagas disease, heart failure and cachexia Arq Bras Cardiol. 2018; 110(6):588-596 Figure 9 – Right chambers showing two endocardial pacemaker metallic leads, one attached to the atrium and the other to the ventricular apex. T- Tricuspid valve. pacemaker metallic leads could be seen, one attached to the atrium and the other to the trabecular portion of the ventricle (Figure 9). On its way through the tricuspid valve, the lead was adhered and covered by a whitish sheath. No cavitary thrombus was seen. The examination of the lungs evidenced an ill-defined brownish nodule, with necrotic center, in the right middle lobe, measuring 2.5 cm in its long axis (Figure 10). The hilar and subcarinal lymph nodes were enlarged, confluent, and had extensive nodular, whitish areas (Figure 11). The liver weighed 2223 g and had a finely granular surface. The microscopic study of the myocardium showed hypertrophied cardiomyocytes, varied focal fibrosis, and focal and mild inflammatory infiltrate. The microscopic study of the lungs and lymph nodes showed extensive chronic granulomatous inflammation with caseating necrosis, including in the nodular area of the pulmonary parenchyma (Figure 12). The search for acid-fast bacilli was positive, with a small number of bacilli in the caseating lesions (not shown). The microscopic study of the liver evidenced diffuse nodular transformation, expansion of the portal spaces and diffusely damaged hepatocytes, characterized by the presence of multiple eosinophilic inclusions in their cytoplasm (Mallory bodies) (Figure 13). (Vera Demarchi Aiello, Prof., M.D.) Anatomopathological diagnoses: - Chronic heart disease, probably of Chagasic etiology, with an aneurysm of the lateral wall; - Productive-caseating tuberculosis in the lungs and mediastinal lymph nodes; - Chronic liver disease progressing to cirrhosis, with characteristics of cellular damage secondary to the chronic use of amiodarone; - Hemothorax. (Vera Demarchi Aiello, Prof., M.D.) Comments The patient had chronic heart disease with arrhythmia, having received specific treatment with pacemaker implantation and prescription of antiarrhythmic drugs. Her clinical condition worsened due to the development of productive-caseating tuberculosis in the lungs and mediastinal lymph nodes, which motivated the final diagnostic investigation. The clinical hypothesis of sarcoidosis was ruled out by the finding of the infectious agent (acid-fast bacilli) in the granulomatous lesions. Despite the lack of diffuse myocarditis on the microscopic study, Chagasic heart disease is the most probable diagnosis, considering the gross morphological aspect of the heart, with fibrous replacement of the left ventricular lateral/inferior wall and the presence of diffuse interstitial fibrosis, although such findings are not characteristic. The microscopic findings in the liver parenchyma point to a type of cell damage related to drug toxicity. Because of the report of this patient having received amiodarone during her disease, we concluded that her liver damage is related to that drug. That type of lesion is characterized by nodular transformation (cirrhosis) and hepatitis with several Mallory 594