Case Presentation: A 67 year old female with no past medical history presented to our emergency department for new onset shortness of breath, chest pain, and palpitations for 90 minutes. Of note, she reported 8 pound weight gain, generalized fatigue, and abdominal distension for several months prior to presentation. Physical exam revealed a heart rate of 192 with an irregularly irregular rhythm. The abdomen was markedly distended with shifting dullness. The rest of physical exam was unremarkable. Pertinent labs included a potassium of 2.9, creatinine of 1.4, and hemoglobin of 11.9. TSH, troponins, and BNP were within normal limits. ECG demonstrated atrial fibrillation with rapid ventricular response. The patient was admitted and started on diltiazem IV with spontaneous cardioversion to normal sinus rhythm overnight. A CT scan of the abdomen showed an abnormally thickened mid sigmoid colon wall with two large (31x28x18cm and 18x12x12cm) intraperitoneal cystic masses. A transvaginal ultrasound confirmed 2 very large cystic lesions. CEA was 3.9 (normal < 3.0) and CA 125 was 48 (Normal 0-30). A colonoscopy showed frond-like/villous completely obstructing large (5 cm) oozing mass in mid-sigmoid colon. The patient had sigmoid colon resection with end colostomy, omentectomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pathology confirmed metastatic colonic mucinous adenocarcinoma. The patient was discharged with referral to tertiary center for aggressive chemotherapy with re-staging, debulking, and intraperitoneal chemotherapy.

Discussion: The importance of the medical interview cannot be understated. History and physical examination alone contribute 73% to 94% of the diagnostic information. Our patient presented with symptoms most concerning to her (palpitations, fast heart rate). If we did not perform a comprehensive interview, we may have missed her metastatic disease.

Atrial fibrillation (AF) has been found to occur with an increased frequency in patients with malignancies. The occurrence of AF in cancer may be related to increased inflammation from comorbid states or direct tumor effects, although no causal relation has been found.

Krukenberg tumors (KT) are metastatic signet ring adenocarcinomas of the ovary accounting only 1-2% of ovarian cancer. Only 11% of KT reported arose from colorectal origin. KT often have some symptoms: abdominal or pelvic pain, bloating, ascites, and/or pain during sexual intercourse. Diagnosis involves biopsy, but one study found that if the CA-125/CEA ratio > 25, an ovarian cancer was found in 82% of cases. Since Krukenberg tumors are metastatic, management is identifying and treating the primary cancer.

Conclusions: A complete history and physical is key. Atrial fibrillation may be a presenting and poor prognostic finding in cancer patients. KT are rare metastatic signet ring adenocarcinomas of the ovary with treatment dependent on the origin of cancer.