European Heart Journal (1992) 13,1592-1593

Endocarditis on a left atrial myxoma J. M. TEN BERG, H. R. J. ELBERS, J. J. A. M. DEFAUW AND H. W. T. PLOKKER

St Antonius Hospital, Nieuwegein, The Netherlands KEY WORDS: Left atrial myxoma, endocarditis. A 55-year-old woman presented with fever and malaise. Three blood cultures were positive for Streptococcus sanguis. A diagnosis of endocarditis was made and the patient was treated with intravenous penicillin and gentamicin. Endocardiography revealed a large left atrial tumour. At operation a myxoma covered by deposits of fibrin was excised. Microscopy revealed massive infiltrates of neutrophils and remnants of bacteria, indicating that this myxoma was a nest for infection. Introduction Atrial myxomas commonly present with symptoms of mitral valve dysfunction, symptoms often overshadowed by fever, malaise, fatigue, weight loss and peripheral emboli, all mimicking infective endocarditis. True infection, however, might be present, since a myxoma may be a perfect infection site. There are very limited data on the combined presence of endocarditis and myxoma. A survey of the literature yielded only six cases'1"61. A patient with a left atrial myxoma and bacterial endocarditis is presented.

Case report A 55-year-old woman presented to her general practitioner in January 1991 with fever up to 38-6 °C, dyspnoea, fatigue, malaise and weight loss from 60 to 55 k. There was no history of a recent surgical or dental procedure nor of intravenous drug abuse. Her symptoms were interpreted to be caused by a common viral infection and she was treated for this. When she did not improve, infected haemorrhoids were suspected to be the cause of her illness and she was admitted to a local hospital in February. On physical examination her body temperature was up to 39-2 °C and a loud first heart sound was heard. Otherwise, no abnormalities were noted. Laboratory studies revealed a white blood cell count of 11-2 mm~3. The erythrocyte sedimentation rate was 127mm.h~'. Urinalysis showed no abnormalities. Three blood cultures were positive for Streptococcus sanguis. A diagnosis of endocarditis was made and the patient was started on intravenous penicillin and gentamicin therapy. A twodimensional echocardiogram revealed a large left atrial tumour which was considered to be a myxoma (Fig. 1). There were no signs of endocarditis. The patient was transferred to our Hospital for surgery. At operation the left atrium was explored and a pedunculated gelatinous mass attached to the atrial septum was excised. Submitted for publication on 6 December 1991, and in revised form 13 April 1992. Correspondence Dr. H W. T. Plokker, Cardiologist, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. 0195-668X/92/111592 + 02 $08.00/0

Figure I Transesophageal four-chamber view, showing a large left atrial myxoma.

Figure 2 Cardiac myxoma consisting of friable, gelatinous tissue, with a distinct mucoid appearance (on the right), and on the left an area with an abnormal gray to white appearance.

Postoperatively her temperature quickly returned to normal and the patient made an uneventful recovery. She was discharged 10 days after surgery. Gross pathologic examination of the tumour revealed two fragments of friable, polypoid and gelatinous tissue, gray to gray-white in appearance with areas of haemorrhage (Fig. 2). Microscopic examination showed a typical © 1992 The European Society of Cardiology

Endocarditis on a left atrial myxoma

1593

appear to be infected. Only six cases of clinical diagnosis of infected left atrial myxoma have been reported so far""*1. In four of these myxomas, microorganisms could be identified. In our patient, blood cultures were positive and collections of fibrin, leucocytes and remnants of bacteria were found on the tumour. These deposits gave the tumour the aspect of being covered with vegetations. Cultures of the myxoma were negative; we have to keep in mind however that this patient had been treated with intravenous antibiotics for some weeks prior to surgery. We conclude that a left atrial myxoma can be a nest for infection. In this situation, more than ever, early surgery seems to be indicated to prevent tumour emboli. Figure 3 The surface of the myxoma focally covered by deposits of fibrin and polymorphonuclear leucocytes; microorganisms could be recognized (Gram stain; 250 x ) , and reproduced here at a reduction of 45%,

myxoma focally covered by deposits offibrin.Within these depositions of fibrin, and in the myxomatous tissue underneath, massive infiltrates of neutrophils and remnants of bacteria were seen (Fig. 3). Cultures of the tumour were negative. Discussion

Although cardiac myxomas often present with symptoms suggesting infectious endocarditis, they seldom

References [1] Malloch CL, Abbott JA, Rapaport E. Left atrial myxoma with bacteremia. Am J Cardiol 1970; 25: 353-8. [2] Graham HV, von Hartitzsh B, Medina JR. Infected atrial myxoma. Am J Cardiol 1976; 25: 658-61. [3] Rogers EW, Weyman AE, Noble RJ, Bruins SC. Left atrial myxoma infected with histoplasma capsulatum. Am J Med 1978; 64: 683-90. [4] Rajpal RS, Leibsohn JA, Liekweg WG el at. Infected left atrial myxoma with bacteremia simulating infective endocarditis. Arch Intern Med 1979; 139: 1176-8. [5] Quinn TJ, Codini MA, Harris AA. Infected cardiac myxoma. Am J Cardiol 1984; 53: 381-2. [6] Frandsen TM, Prichard JG, Store SO Streptococcus viridans bacteremia associated with atnal myxoma. Am Heart J 1985; 110: 180-1.

Endocarditis on a left atrial myxoma.

A 55-year-old woman presented with fever and malaise. Three blood cultures were positive for Streptococcus sanguis. A diagnosis of endocarditis was ma...
2MB Sizes 0 Downloads 0 Views