Case Presentation: A 59-year-old female with a history of metabolic associated fatty liver disease, obstructive sleep apnea, recent cholecystectomy and gastroesophageal reflux disease presented to the emergency department with rigors, lethargy and R sided chest pain. Her presentation was notable for temperature to 101F and tachycardia. Lab work demonstrated no leukocytosis (WBC 7.7), elevated procalcitonin (0.85), and elevated liver function tests (AST 170 / ALT 213). Her presentation, recent exposure to kangaroos and recent travel to Florida prompted a very broad infectious workup. She was evaluated for common and uncommon infections, including bacterial, zoonotic, and viral causes. Results were relevant for negative respiratory viral testing, negative urinalysis, negative hepatitis panel, negative blood culture, unremarkable chest x-ray, and right upper quadrant ultrasound with findings consistent with post cholecystectomy changes. She received 1 day of Vancomycin and Piperacillin-Tazobactam prior to transition to doxycycline per Infectious Disease team recommendations for presumed rare zoonotic infection, such as Q fever, as we were awaiting definitive results. Given a largely negative infectious work-up, alternative diagnoses were pursued which uncovered a CT PE negative for embolus but demonstrated a diffusion defect. Echocardiogram was unable to appropriately visualize the defect given difficult windows, therefore a CT LAA was pursued which showed a 6mm filling defect consistent with an atrial myxoma. At this juncture, she was transitioned off antibiotics per Infectious Disease team’s instructions given a more plausible alternative diagnosis and persistently negative infectious studies. Her symptoms were deemed most likely driven by her cardiac atrial myxoma. Cardiothoracic surgery was consulted, and she was discharged home with close follow up to pursue MRI imaging and definitive surgical repair.
Discussion: Cardiac myxomas are the most common primary tumor of the heart. Myxomas are more commonly detected in females, in the 4th to 6th decade of life, and 75% arise from the left atrium as seen in this patient. Typical symptoms of presentation include dyspnea on exertion and orthopnea secondary to mitral valve pathology or heart failure due to obstructive effect of the mass. Alternatively, thromboembolic symptoms can occur due to systemic embolization leading to tachycardia, hypoxia or sudden death. While these are the more common presenting symptoms, there can be an indolent course primarily driven by constitutional symptoms including fever, malaise, and arthralgias. These were the primary symptoms of our patient as it had not yet progressed in size or spread to be obstructive nor embolized. The reason for these symptoms stems from cardiac myxomas tendency to overexpress cytokine IL-6, which is a common acute phase reactant and thus leads to diffuse immunoregulatory effects such as fever.
Conclusions: Fever should always evoke a broad differential for hospitalists, often focusing on infectious and inflammatory sources first. However, when met with persistently negative tests, it is important to consider more rare etiologies. Targeted imaging studies can yield important results as seen in this patient.
