Oct 29, 2009 0
Mar 5, 2009 0
Abdominal pain: repeat visit
A 41 year old male presented to the ED with diffuse abdominal pain. Vital signs were normal and bloodwork was unremarkable for abnormalities. Past medical history was benign per the patient. A CT of the abdomen and pelvis with PO and IV contrast was ordered due to the severity of pain on exam, which demonstrated”a 3.0 cm mass with peripheral ring enhancement during arterial phase in the right hepatic lobe. The lesion has become isodense in the parenchymal phase. This is likely a cavernous hemangioma.” The patient was discharged home and set up for follow up in the medical clinic. Two weeks later he returned to the ED, stating that the pain had returned and was now radiating to his back. He again denied medical problems, alcohol, tobacco, or recreational drug use. His vital signs were normal and his exam again reveals diffuse abdominal tenderness to palpation, with no rebound or guarding. Lab work was unchanged. What would you do next?
The resident and attending performed a FAST exam to assess for free fluid:
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!
Feb 23, 2009 0
Syncope with a history of Marfan’s Disease…
A 53 yo woman collapsed in a crowd while celebrating inuaguration day on the mall in January of 2009. EMS was called by bystanders, who arrived to find the patient supine and in severe distress. She was able to reveal a medical history of Marfan’s disease, then became hypotensive and diaphoretic. She was immediately transported to the emergency department, where she was noted to be bradycadic, hypotensive, and unresponsive. She was intubated, central venous access was obtained, and a comprehensive workup including a chest and abdominal CT was performed. A bedside echocardiogram and abdominal ultrasound to evaluate the aorta were also performed. Initially no contrast was seen within the aorta, limiting the study for visualization of dissection or an intimal flap. However, upon repeat evaluation, the study reveals a complex dissection flap extending from the ascending aorta to bilateral iliac arteries, involving the L subclavian, common carotid, and renal artery. These bedside ultrasound images were obtained within the initial 20 minutes of the resuscitation:
Figure 1: Transverse view of the descending aorta. A low frequency, phased array probe is used for all images. Here the probe marker is oriented toward the patient’s R shoulder. Note the hyperechoic dissection flap seen in this cross-sectional view of the vessel.
Figure 2: Longitudinal view of the descending aorta. In this view the bright dissection flap is seen extending the length of the vessel at its posterior aspect.
Figure 3: A suprasternal view of the ascending aorta is obtained by placing the probe in the patient’s suprasternal notch, marker oriented straight up toward the patient’s head. The dissection flap is visible in this view as well, mandating surgical involvement.
Conclusion: The patient was taken emergently to the OR where she experienced complete hemodynamic collapse. Resuscitative efforts were unsuccessful, and she eventually died of complications of her disease.
Recommended reading: Bilku R, Steadman C, Jordan P. Acute deBakey type III (or Stanford type B) aortic dissection diagnosed by transthoracic
echocardiography. Journal of American Society of Echocardiography. 2008; 21(9): 1080-1083.
Special thanks to Dr.s Annette Dorfman and Jeremy Berman for their scanning skills and excellent clinical care!
