Case 39

50 yo f p/w palpitations for one week.  Pt having viral URI symptoms for the previous month and diagnosed with bronchitis. A CXR ordered for bronchitis showed b/l pleural effusions. For the last week, pt has been having intermittent palpitations.  No history of arrhythmia. No cp. Pt denies sob at rest or pleuritic type CP.  No recent illnesses. No fever.Pt denies any previous cardiac history.  No family history of vascular disease, early MI, or PE.

ROS
no fever, no chills, no ha, no visual changes, no sob, no dyspnea, no pleuritic type cp, no abdominal pain, no dysuria, no focal weakness, No muscle aches, no joint pain, no rashes, no hx of autoimmune disease

PHYSICAL EXAM
VS T 98.0 HR 69 RR 18 1131/75 100% RA
CONST well appearing, well developed mid-aged female appears comfortable on bed in nad
HEAD/NECK atraumatic, normcehpalic
CARD s1,s2, rrr, no appreciated m/r/g, no carotid bruit
RESP cta b/l, no w/r/r, nl work of breathing at rest
ABD soft, nd, nt, no pulsatile mass
SKIN no acute rash
NEURO alert and oriented x 3, grossly nl
EKG NSR 68 bpm, QT 378 no ST segment abnormalities

As a dedicated ED provider you perform a cardiac ultrasound as part of your exam.  See the video below.

QUESTIONS

  1. What is your differential diagnosis?
  2. What is the most likely cause of this pathologic finding?
  3. What immediate tests are necessary?
  4. What service needs to be involved with patient’s care?
  5. What is the definitive treatment for this patient?

ANSWERS

  1. Endocardial tumor (atrial myxoma, rhabdomyoma, lipoma, fibroma), cardia valve mass, Endocarditis vegetation, iatrogenic foreign body, collagen vascular disease, cardiac hypertrophy
  2. Left atrial myxoma
  3. STAT bedside transthoracic ECHO
  4. Need to consult CT surgery for removal.
  5. Prompt resection is required after diagnosis due to the risk of embolization or cardiovascular complications.

DISCUSSION

What we see here is most likely an atrial myxoma, the most common primary cardiac neoplasm (1). In our 2 week rotation we were lucky enough to see the classic ultrasound presentation of a myxoma, with 80% found in the left atrium and 15% demonstrating the “tumor plop” (2) into the left ventricle, both seen in the video above.

Myxomas largely develop their size and mass through production of VEGF, which essentially causes angiogenesis for the tumor and increases nutrient resources. Thus, the tumor may grow large in size, such as taking the entire atrium, and as a result the patient may present with constitutional symptoms of weight loss, fever, and vague lab abnormalities like elevated ESR and CRP.

Fortunately, these potentially large myxomas are connected to the atrial wall via a stalk, making them a simpler case for cardiac resection, relatively. However, this also makes them a risk for embolization and sudden cardiac death, and thus requires prompt resection once diagnosed. This procedure has a 5% mortality rate (3,4), and may result in recurrent myxomas and rhythm abnormalities, which may indicate the need for the more difficult cardiac transplant, relatively. Lastly, while the typical myxoma has a smooth and circumscribed surface, 35% of myxomas have a friable surface which may embolize (2). So consider myxoma emboli somewhere lower on your differential in your next altered febrile patient, and rule it out in the ED with your newly refined cardiac ultrasound skills.

  1. Pucci A, Gagliardotto P, Zanini C, et al. Histopathologic and clinical characterization of cardiac myxoma: review of 53 cases from a single institution. Am Heart J 2000; 140:134.
  2. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001; 80:159.
  3. Keeling IM, Oberwalder P, Anelli-Monti M, et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg 2002; 22:971.
  4. Bakaeen FG, Reardon MJ, Coselli JS, et al. Surgical outcome in 85 patients with primary cardiac tumors. Am J Surg 2003; 186:641.