Case Presentation:

A 71-year-old woman with early-onset Alzheimer’s dementia presented after a fall at an inpatient psychiatric facility where she had been admitted for treatment of agitation, yelling and aggressive behavior. Prior to onset of these symptoms she ambulated, took meals with assistance, and was able to recognize her life partner. Further history divulged episodes of tachycardia, profuse diaphoresis, and 30-pound weight loss over seven weeks. Physical examination revealed a cachectic elderly female in a state of severe agitation, regular tachycardia, and an early diastolic sound consistent with a “tumor plop.” An electrolyte panel, renal function, blood counts, liver function studies, urinalysis, and ammonia level were normal. CT scan with IV contrast of the chest, abdomen and pelvis was performed, revealing a 3×3 cm left atrial mass (figure). Transthoracic echocardiogram revealed a mobile, pedunculated tumor attached to the intra-atrial septum, consistent with an atrial myxoma. MRI of the brain showed no acute infarcts, hemorrhages or mass lesions.

The patient’s aggression and agitation continued throughout her hospital stay. Due to inability tolerate oral medications and previous dystonic reactions to antipsychotics, she was managed with IV lorazepam. Resection of the left atrial myxoma was discussed but return to baseline was not considered a likely outcome. Her partner agreed that her symptoms would be best managed by the hospice service and she was discharged to an inpatient hospice facility where she died the following week.

Discussion: Cardiac myxomas are the most common primary cardiac tumor, occur most frequently in the left atrium, and have a female predominance. They are thought to originate from primitive multipotential mesenchymal cells, and can secrete the pro-inflammatory cytokine interleukin-6. Cardiac myxomas can present with cardiovascular or neurological complications such as congestive heart failure, cardiac arrhythmia and/or embolic stroke. Given the abrupt onset of severe agitation, constitutional symptoms, and an otherwise unrevealing workup, the neuropsychiatric symptoms in this case were thought to represent the late-stage effects of a cardiac myxoma. Changes in behavior due to cardiac myxoma are infrequently reported, especially in absence of embolization or metastatic spread on neuroimaging. Treatment for cardiac myxomas is surgical resection which has a low recurrence rate (1-5%).

Conclusions: Cardiac myxomas are rare primary cardiac tumors that have the capacity to cause cardiovascular and neurological symptoms including behavioral disturbances. Hospitalist physicians must be aware of the presentation of cardiac myxoma and it’s potential complications.