Case Presentation
A 55 year old female presented to the Emergency Department having woken
up acutely short of breath. Prior to admission she had been under
investigation for chronic diarrhoea, weight loss and lethargy. She had
no prior cardiac history. Plain chest radiograph demonstrated bilateral
pulmonary infiltrates and arterial blood gas analysis showed type 1
respiratory failure. The initial working diagnosis was of atypical
pneumonia, and endo-tracheal intubation was performed due to worsening
hypoxaemia. During transfer to critical care the patient was noted to be
dysrhythmic on electrocardiograph (ECG) monitoring.
Over the next 24 hours, the patient’s respiratory function improved
however, she was found to have new right hemiparesis and a computed
tomography (CT) brain scan diagnosed an acute ischaemic infarction in
the left parietal lobe. Aspirin was started and the patient was
extubated. Following extubation her respiratory function began to
deteriorate again, and the atypical pneumonia screen was negative.
Pulmonary oedema was therefore considered as a possible diagnosis and so
a FICE scan was performed at the bedside. This revealed a large mass in
the left atrium which prompted a CT chest, abdomen and pelvis and
trans-oesophageal echocardiography (TOE) as part of the pre-operative
patient work-up for cardiothoracic surgery.
The FICE scan demonstrated a large left atrial mass extending into the
left ventricle through the mitral valve (Figures a and b). This was best
appreciated on the apical four chamber view as demonstrated in Figure a.
Further imaging performed by a specialist transoesophageal
echocardiographer confirmed a 10cm x 3cm cystic mass (Figure c)
resulting in functional mitral stenosis (Figure d) and acute pulmonary
oedema. Coronary angiography showed no vessel disease, and the patient
was immediately taken to theatre for excision of the mass. The
post-operative recovery period was uncomplicated, and the patient was
extubated and went on to rehabilitate. Histological analysis showed the
tumour was a cardiac angiosarcoma.
The parietal lobe stroke was presumed to be an embolic event secondary
to the left atrial tumour. Debris from the left pulmonary vein removed
during surgery had the appearance of reactive blood clot. Magnetic
Resonance Imaging (MRI) of the brain following surgery showed areas of
diffusion restriction in left middle cerebral and posterior cerebral
artery territories suggestive of embolic phenomena not visualised on CT
scanning.