ATRIAL MYXOMA MASQUERADES-ROLE OF POINT-OF-CARE ULTRASOUND IN EMERGENCY DEPARTMENT

Abstract

INTRODUCTION

Myxomas are rare, accounting for 50% of benign primary cardiac tumors. Due to its versatile presentation ranging from cardiac, embolic, neurological and systemic manifestation timely diagnosis is a challenge but not impossible. We present a case of 62 year old male with a transient episode of neurologic dysfunction that was diagnosed with atrial myxoma by Point-of- Care Ultrasound (PoCUS).
CASE DESCRIPTION
A 62 year old man with previous history of stroke in 2015 was found to be less responsive in Radiology Department while booking an ultrasound appointment. Patient’s initial Glasgow Coma Scale (GCS) was 11/15 (E4V1M6). He gradually regained orientation and responsiveness in ED. Patient was tachypneic with a respiratory rate of 32, oxygen saturation of 96%, blood pressure 164/99mmHg and heart rate 112 beats/min. Patient had a systolic murmur with bibasal rales. Neurological examination revealed cerebellar signs. Electrocardiogram showed ST depression in lateral leads. PoCUS revealed an oscillating left atrial mass protruding into left ventricle. Patient was started on oxygen supplementation and underwent urgent computed tomography scan of the brain (CT Brain). Comparison made with previous CT Brain in 2015 showed multifocal chronic infarcts with underlying small vessel disease, cerebral atrophy and no intracranial bleed. Formal echocardiogram (ECHO) showed a single oscillating mass measuring 6.3 x 5.1cm seen in left atrium attached to interatrial septum, pathognomonic of atrial myxoma. Patient was treated as atrial myxoma complicated with transient ischemic attack (TIA) and started on warfarin. Unfortunately, he declined any surgical intervention.
DISCUSSION
Cardiac myxomas are the most common primary cardiac tumor in adults. The neurologic signs and symptoms seen in myxoma are usually a result of embolization. Emboli are most often myxomatous but may also arise from thrombus adherent to the tumor. Early diagnosis of atrial myxoma is important as surgical intervention yields high cure rate and prevents complications.
CONCLUSION
Atrial myxomas are rare, but should be considered as a differential diagnosis of multiple cerebral infarctions in patients with stroke .In this case, PoCUS was useful to aid with early diagnosis and treatment before new embolic or cardiac complication appears.