Case Presentation: A twenty-six year old female was admitted for further evaluation after a Transthoracic Echocardiogram (TTE) showed three cardiac masses in the left and right atrium. Initial symptoms included near syncopal episodes, exertional dyspnea and fatigue. Further history revealed that the patient had right tonsillar swelling with some difficulty swallowing two months prior to admission that was treated with amoxicillin and methylprednisolone. On admission, she was afebrile with heart rate of 140 bpm despite rest and hydration. Physical examination and laboratory data were grossly unremarkable. Both TTE and Cardiac MRI revealed a large left atrium polypoid mass extending to the mitral valve and a right atrium mass extending into the right ventricle. Positron emission tomography CT (PET-CT) showed markedly hypermetabolic intracardiac masses, pericardial thickening, and mediastinal and bilateral hilar adenopathy. Biopsy of the right tonsil was consistent with Epstein Barr virus (EBV) positive Diffuse large B cell lymphoma (DLBCL). Hyper CVAD therapy (cyclophosphamide, vincristine sulfate, doxorubicin hydrochloride, methotrexate, cytarabine, and dexamethasone) was initiated with significant regression of the intracardiac mass and near resolution of lymphadenopathy.
Discussion: Pre-syncope and persistent tachycardia in a previously healthy young adult can be easily missed in clinical practice as these presentations are usually considered evidence of a benign condition. Here, we described a case of a previously healthy 26-year-old female who presented with these symptoms and was found to have bi-atrial mass on TTE. The cardiac masses and previous tonsil swelling responding to steroid treatment triggered our suspicion of hematological malignancy, which was subsequently confirmed by imaging and pathology results. Syncope or presyncope is one of the most commonly encountered initial presentations, however, cardiac mass is a rare etiology. Malignant tumors only constitute approximately 15% of primary cardiac tumors with sarcomas being the most common[1]. Typically, males >60 years of age are affected. The clinical presentation of these cardiac malignant tumors is myriad, ranging from asymptomatic detection on imaging tests ordered for other reasons to shock or aborted sudden cardiac death. Common symptoms include dyspnea, arrhythmia, chest pain and constitutional complaints[2]. Systemic chemotherapy is the mainstay of treatment and should be started as soon as diagnosis is made[3]. The favorable clinical outcome for our patient should be attributed to the thorough medical history taking, appropriate clinical workups and effective multidisciplinary approach.
Conclusions: Cardiac mass is a rare but critical etiology for syncope which can be life threatening if undiagnosed. This case highlights the importance of comprehensive history taking and appropriate targeted diagnostic evaluation as the clinical manifestation of cardiac malignancy can be non-specific and can be easily misattributed to other common conditions or overlooked.