Case Presentation: A 79 year old male with past medical history of COPD, Parkinson’s disease, HTN, hyperlipidemia, and GERD presented to a local hospital after an episode of acute chest pain lasting a few minutes. Further history revealed he had been having dyspnea with exertion for 2 months and had tried multiple rounds of steroids and antibiotics. At the local hospital, his vital signs were within normal limits. Remarkable labs included WBC 12.9. A HS troponin, BMP. BNP, CRP were normal. An EKG showed a RBBB and L fasicular block, which was noted to be present on prior EKG. A CT showed a moderate to large pericardial effusion and moderate emphysema. He was transferred to EUHM for further management of the pericardial effusion. Patient remained chest pain free after the initial episode. A repeat echo at EUHM showed the pericardial effusion to be small. Cardiology was consulted and recommended a cardiac PET-as this showed no ischemia no further workup was recommended by cardiology. Interestingly, the CT portion of cardiac pet showed a moderate sized, complex-attenuating loculated pericardial effusion with associated pericardial thickening and enhancement, favored to be secondary to pericarditis. The case was discussed with radiology regarding further imaging as clinically patient did not have pericarditis. A Chest MRI was recommended which showed a 11.8 x 9.1 x 17 cm mass with progressive heterogenous enhancement measuring arising from the right pericardial space and extending superiorly along the ascending aorta, right brachiocephalic artery and compression of the SVC. He underwent a VATS biopsy with pathology showing malignant spindle cell myxoid neoplasm. He was seen by oncology and as an outpatient initiated on chemotherapy and later proton therapy.
Discussion: Cardiac tumors are rare with autopsy findings between 0·001% to 0·030%. About 90% of cardiac tumors are categorized as benign(1) Of the malignant cases, primary sarcomas are the largest group in the category of malignant primary cardiac tumors in adults. This case had a pathology of malignant spindle cell myxoid neoplasm which is classified as a sarcoma. The clinical presentation can be variable and is related to tumor location and size (2). Though 2D TTE is frequently the first imaging modality that is ordered based on the patient’s symptoms, it has a limited ability to evaluate tissue and can have a restricted field of view. Cardiac MRI can provide better information regarding characterization of the tumor and tumor invasion(3), and Cardiac CT is an alternative to cardiac MRI.
Conclusions: This case shows the importance of clinical judgement in the further workup of dyspnea and the multidisciplinary approach needed for proper diagnosis of primary cardiac tumors.
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