The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.04.007
Visual Diagnosis in Emergency Medicine
BEDSIDE DIAGNOSIS OF AN UNUSUAL CAUSE OF DYSPNEA Shing Ching, MBBS and Kai Ming Li, MBBS, MRCP, FHKAM Accident and Emergency Department, United Christian Hospital, Kowloon, Hong Kong Reprint Address: Shing Ching, MBBS, Accident and Emergency Department, United Christian Hospital, Kowloon, Hong Kong
oscillating, well-circumscribed, heterogeneous mass prolapsing through the mitral valve that was attached to the inter-atrial septum (Figure 2; Video 1). Color Doppler showed signal aliasing (the misregistration of flow toward
CASE REPORT A 59-year-old previously healthy Chinese woman presented to the emergency department with 6 months of progressive palpitation, exertional dyspnea, postural dizziness, subjective fever, and a painless abdominal mass. She neither smoked nor drank. Her family history was negative for colorectal cancers or congenital heart disease. Physical examination was notable for an afebrile patient with a regular pulse, normal heart sounds, and a nontender, hard, irregular, fixed mass at left lower quadrant of abdomen. Digital rectal examination found no mass and brownish stool. Other systems were unremarkable. Laboratory studies showed a hemoglobin drop from 13 g/dL to 10 g/dL and a declining mean corpuscular volume (MCV) (from 90 fL to 80 fL) over 3 months. Carcinoembryonic antigen was elevated at 15.1 mg/L. Blood cultures were negative. Chest x-ray study showed left atrial enlargement, but a normal cardiothoracic ratio (Figure 1). Resting electrocardiography showed sinus rhythm and nonspecific ST-T abnormality. Bedside transthoracic echocardiography with a hand-held device (V-scanÔ, GE Healthcare, Norway) revealed a large
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
Figure 1. A plain chest x-ray study shows left atrial enlargement (arrow).
RECEIVED: 20 January 2015; FINAL SUBMISSION RECEIVED: 20 March 2015; ACCEPTED: 7 April 2015 1
2
S. Ching and K. M. Li
Figure 2. (A) Apical four-chamber view. (B) Apical 4-chamber view with color Doppler in diastole. (C) Parasternal long-axis view. (D) Parasternal short-axis view at mitral valve level in diastole. The arrows indicate the left atrial myxoma attached to the interatrial septum best seen in (B).
the probe as away when flow exceeds certain velocity, i.e., red as blue) of mitral inflow suggestive of high-pressure gradient and significant obstruction. The right atrium and right ventricle were mildly enlarged. The finding was corroborated on transesophageal echocardiography. The mass was resected under cardiopulmonary bypass; pathology confirmed atrial myxoma. A subsequent colonoscopy revealed a circumferential obstructive mass located 30 cm from anal verge. Biopsy found adenocarcinoma. The patient underwent laparoscopic hemicolectomy with good recovery.
DISCUSSION We reported a female patient presenting with palpitation, dyspnea, subjective fever, and an incidental abdominal mass. Although it was tempting initially to attribute her symptoms to chronic blood loss and malignancy, the chest x-ray study suggested otherwise. The most common cause of left atrial enlargement is left ventricular dysfunction, as would be evident by a high cardiothoracic ratio; however, isolated left atrial enlargement, as in this case, should alert the clinician to mitral inflow obstruction. Auscultation of the characteristic mid-diastolic rumble is often not possible in the noisy emergency department, so its absence should not be reassuring. The next step is to image the valve. Echocardiography is the ideal imaging
modality; besides anatomic data, hemodynamic information can be obtained that helps gauge disease severity and urgency of intervention. Miniaturization of ultrasound technology into hand-held devices allows rapid bedside evaluation, and significantly expedited management in our patient. Atrial myxoma is one of the most common benign intracardiac tumors (1). It is typically found in the left atrium attached to the interatrial septum by a stalk, which is best visualized in parasternal short-axis and subcostal views on echocardiography. It characteristically ‘‘plops’’ into the mitral inlet in diastole and returns to the left atrium in systole. As it grows to a size that obstructs the mitral inflow, symptoms due to elevated left atrial pressure may develop, including dyspnea, cough, and atrial fibrillation (2). It can also be a source of emboli when fragments dislodge. Besides mechanical complications, some patients experience low-grade fever, weight loss, and poor appetite that can sometimes lead to unrewarding and extensive workup for cancer and autoimmune conditions. The only definitive treatment is surgery. Most myxomas are single; however, if incompletely resected, they may recur at the same location (3). This patient had a concomitant colonic cancer in addition to a left atrial myxoma. Multiple factors may have contributed to her symptoms, including dysrhythmia, anemia, and tumor growth. On follow-up, she was found to have paroxysmal atrial fibrillation on Holter recording.
An Unusual Cause of Dyspnea
REFERENCES 1. Reynen K. Frequency of primary tumors of the heart. Am J Cardiol 1996;77:107. 2. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001;80:159–72. 3. Martin LW, Wasserman AG, Goldstein H, Steinberg JS, Mills M, Katz RJ. Multiple cardiac myxomas with multiple recurrences: un-
3 usual presentation of a ‘‘benign’’ tumor. Ann Thorac Surg 1987;44: 77–8.
SUPPLEMENTARY DATA Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2015.04.007.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
http://dx.doi.org/10.1016/j.jemermed.2015.04.007
Visual Diagnosis in Emergency Medicine
BEDSIDE DIAGNOSIS OF AN UNUSUAL CAUSE OF DYSPNEA Shing Ching, MBBS and Kai Ming Li, MBBS, MRCP, FHKAM Accident and Emergency Department, United Christian Hospital, Kowloon, Hong Kong Reprint Address: Shing Ching, MBBS, Accident and Emergency Department, United Christian Hospital, Kowloon, Hong Kong
oscillating, well-circumscribed, heterogeneous mass prolapsing through the mitral valve that was attached to the inter-atrial septum (Figure 2; Video 1). Color Doppler showed signal aliasing (the misregistration of flow toward
CASE REPORT A 59-year-old previously healthy Chinese woman presented to the emergency department with 6 months of progressive palpitation, exertional dyspnea, postural dizziness, subjective fever, and a painless abdominal mass. She neither smoked nor drank. Her family history was negative for colorectal cancers or congenital heart disease. Physical examination was notable for an afebrile patient with a regular pulse, normal heart sounds, and a nontender, hard, irregular, fixed mass at left lower quadrant of abdomen. Digital rectal examination found no mass and brownish stool. Other systems were unremarkable. Laboratory studies showed a hemoglobin drop from 13 g/dL to 10 g/dL and a declining mean corpuscular volume (MCV) (from 90 fL to 80 fL) over 3 months. Carcinoembryonic antigen was elevated at 15.1 mg/L. Blood cultures were negative. Chest x-ray study showed left atrial enlargement, but a normal cardiothoracic ratio (Figure 1). Resting electrocardiography showed sinus rhythm and nonspecific ST-T abnormality. Bedside transthoracic echocardiography with a hand-held device (V-scanÔ, GE Healthcare, Norway) revealed a large
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
Figure 1. A plain chest x-ray study shows left atrial enlargement (arrow).
RECEIVED: 20 January 2015; FINAL SUBMISSION RECEIVED: 20 March 2015; ACCEPTED: 7 April 2015 1
2
S. Ching and K. M. Li
Figure 2. (A) Apical four-chamber view. (B) Apical 4-chamber view with color Doppler in diastole. (C) Parasternal long-axis view. (D) Parasternal short-axis view at mitral valve level in diastole. The arrows indicate the left atrial myxoma attached to the interatrial septum best seen in (B).
the probe as away when flow exceeds certain velocity, i.e., red as blue) of mitral inflow suggestive of high-pressure gradient and significant obstruction. The right atrium and right ventricle were mildly enlarged. The finding was corroborated on transesophageal echocardiography. The mass was resected under cardiopulmonary bypass; pathology confirmed atrial myxoma. A subsequent colonoscopy revealed a circumferential obstructive mass located 30 cm from anal verge. Biopsy found adenocarcinoma. The patient underwent laparoscopic hemicolectomy with good recovery.
DISCUSSION We reported a female patient presenting with palpitation, dyspnea, subjective fever, and an incidental abdominal mass. Although it was tempting initially to attribute her symptoms to chronic blood loss and malignancy, the chest x-ray study suggested otherwise. The most common cause of left atrial enlargement is left ventricular dysfunction, as would be evident by a high cardiothoracic ratio; however, isolated left atrial enlargement, as in this case, should alert the clinician to mitral inflow obstruction. Auscultation of the characteristic mid-diastolic rumble is often not possible in the noisy emergency department, so its absence should not be reassuring. The next step is to image the valve. Echocardiography is the ideal imaging
modality; besides anatomic data, hemodynamic information can be obtained that helps gauge disease severity and urgency of intervention. Miniaturization of ultrasound technology into hand-held devices allows rapid bedside evaluation, and significantly expedited management in our patient. Atrial myxoma is one of the most common benign intracardiac tumors (1). It is typically found in the left atrium attached to the interatrial septum by a stalk, which is best visualized in parasternal short-axis and subcostal views on echocardiography. It characteristically ‘‘plops’’ into the mitral inlet in diastole and returns to the left atrium in systole. As it grows to a size that obstructs the mitral inflow, symptoms due to elevated left atrial pressure may develop, including dyspnea, cough, and atrial fibrillation (2). It can also be a source of emboli when fragments dislodge. Besides mechanical complications, some patients experience low-grade fever, weight loss, and poor appetite that can sometimes lead to unrewarding and extensive workup for cancer and autoimmune conditions. The only definitive treatment is surgery. Most myxomas are single; however, if incompletely resected, they may recur at the same location (3). This patient had a concomitant colonic cancer in addition to a left atrial myxoma. Multiple factors may have contributed to her symptoms, including dysrhythmia, anemia, and tumor growth. On follow-up, she was found to have paroxysmal atrial fibrillation on Holter recording.
An Unusual Cause of Dyspnea
REFERENCES 1. Reynen K. Frequency of primary tumors of the heart. Am J Cardiol 1996;77:107. 2. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001;80:159–72. 3. Martin LW, Wasserman AG, Goldstein H, Steinberg JS, Mills M, Katz RJ. Multiple cardiac myxomas with multiple recurrences: un-
3 usual presentation of a ‘‘benign’’ tumor. Ann Thorac Surg 1987;44: 77–8.
SUPPLEMENTARY DATA Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2015.04.007.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
