Mar 5, 2009 0
Abdominal pain: repeat visit
Figure 1: RUQ with no free fluid seen on FAST exam
The LUQ and pelvis were also negative for free fluid or noted abnormalities. A four chamber view of the heart performed as part of the FAST exam is shown below:
Figure 2: Apical 4-chamber view of the heart
Note the presence of a hyperechoic mass-like structure in the right atrium; concerning for thrombus vs. mass. Cardiology was then consulted and a complete TTE was done in ED confirming the presence of an atrial mass. The patient was admitted for further work-up, where a CT of the chest revealed a 4 cm filling defect in the right atrium concerning for a myxoma. The CT also revealed what appeared to be lytic lesions in the spine. The patient was found to be HIV positive, and on hospital day 5 underwent radical resection of the right atrium, described as a spindle cell carcinoma on the initial pathology report. The final report from Johns Hopkins pathology revealed grade 3 Angiosarcoma.
Cardiac tumors are uncommon, usually benign myxomas, although lipomas and fibromas may occur. Rare primary malignant tumors include sarcomas (especially angiosarcoma), as well as mesotheliomas and lymphoma. Metastatic tumors and venous extension (renal, adrenal, and liver cancer) may also involve the heart. Myxomas usually attach to interatrial septum on the left, and are slow growing masses that often present with embolic phenomenon. Surgery is curative in most cases; 5% recur. Angiosarcomas typically involve the pericardium and left atrium, and may cause obstruction with signs and symptoms of R sided heart failure. Surgery is the mainstay of therapy, combined with radiation, chemo, and immunotherapy. Mean survival for most primary cardiac sarcomas is less than 1 year.
The practitioners in this case imaged the heart as part of the FAST exam and were able to identify this extremely unusual pathology. And while they were not initially suspicious of a cardiac etiology of his symtoms, their use of an alternative imaging modality provided important information about the underlying cause of the patient’s symptoms. This case highlights the fact that the presence of persistent symptoms in the face of recent negative imaging should prompt a re-evaluation of the patient’s complaint.
Recommended reading: Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. Acad Emerg Med. 2003; 10: 1054-1058.
Special thanks to Dr. Ali Pourmand and Dr. Pete Dowiatt for their excellent clinical care and scanning skills!
