Case Presentation: A 39-year-old male with a history of primary refractory T-cell lymphoblastic leukemia/lymphoma (T-ALL) complicated by superior vena cava (SVC) syndrome, and Guillain Barre Syndrome secondary to chemotherapy presented with worsening right-sided pleuritic chest pain. He denied dyspnea or difficulty during exertion. On exam, blood pressure was 106/74 mmHg, heart rate was 123 bpm and respiratory rate was 23 bpm. Labs were notable for troponin I of 0.07 ng/mL and EKG showed sinus tachycardia, bi-atrial enlargement with T-wave inversions (TWI) in leads I, aVL, V3-V6. Four hours later, his chest pain continued, and a follow-up EKG now showed 3-mm ST-segment elevations in V3 and V4 along with deepening TWI in leads V4-V6. Urgent left heart catheterization demonstrated normal coronary arteries with increased left ventricular end-diastolic pressure at 20 mm Hg. Even without evidence of infarction, troponin continued to increase to 0.13 ng/mL. Echocardiogram was notable for ejection fraction of 65% with an echogenic appearance of the right ventricular free wall extending to the left ventricular apex. Right ventricular size was normal while left ventricular size was small at 3.8 cm and there was a trivial pericardial effusion without signs of cardiac tamponade. Computed tomography of the chest showed multiple necrotic masses abutting the left heart border and the right atrium with nodular thickening of the pericardium, concerning for metastasis. Cardiac MRI was not pursued as the patient’s respiratory status declined and he was unable to lie flat. Taken together, these findings were most consistent with cardiomyopathy from lymphomatous infiltration of the myocardium with concurrent subacute pericarditis.
Discussion: Metastatic involvement of cardiac structures is the most common malignancy involving the heart. Non-Hodgkin’s lymphoma is a group of hematologic malignancies that collectively accounts for 20% of cardiac metastases. Patients with cardiac lymphoma present with chest pain in about 25% of cases, whereas dyspnea is the most common complaint. Occasionally there is involvement of the coronary arteries, which can cause angina and clinical signs of myocardial infarction. T-cell lymphomas with cardiac involvement have been rarely reported however, given its propensity for mediastinal involvement, it is important to be aware of this potential complication.
Conclusions: We encourage hospitalists to maintain a high suspicion for cardiac involvement in patients with a history of lymphoma who present with dyspnea, chest pain or new arrhythmia and to involve the cardiology and hematology teams promptly. Although prognosis is poor, early recognition and aggressive management may provide better outcomes for these patients.