Case report: left atrial Myxoma causing elevated C-reactive protein, fatigue and fever, with literature review

Abstract

Background: A cardiac myxoma in a young person may pose a diagnostic challenge as symptoms may be variable and the differential diagnosis is wide. The differential diagnosis can include rheumatic mitral valve disease, pulmonary hypertension, endocarditis, myocarditis and vasculitis.

Case presentation: This case report involves a 49 years old female with a 2.8 cm × 3.4 cm myxoma in the left atrium causing mitral valve obstruction. She presented with fatigue, fever of unknown origin, transient ischemic attack and shortness of breath. Prompt surgery is often recommended due to the risk of embolic complications or complete obstruction. Due to her symptoms, patient underwent successful cardiothoracic surgery to excise the myxoma within 2 weeks of confirmation by cardiac echocardiography.

Conclusion: This case also emphasizes the diagnostic challenge as symptoms may be variable, ranging from fatigue, fever and shortness of breath to transient ischemic attack and at worst, sudden cardiac death. In conclusion, if a cardiac mass is suspected, echocardiography should be performed early. Surgical resection is curative and recurrence rate is very rare in sporadic isolated myxomas, however, recurrence can be higher in genetic diseases associated with increased frequency of myxomas such as Carney complex. This subpopulation of patients may present further research opportunity to learn more about the perioperative management of patients with myxomas such as determining the optimal time to surgical intervention and decision to anticoagulate.

Keywords: Cardiac mass; Cardiothoracic surgery; Carney complex; Fever; Myxoma; Stroke.

Fig. 1

a: Transthoracic echocardiogram (TTE) apical view shows a large left atrial mass at the level of the mitral valve during systole (arrow). Abbreviations: LA-left atrium, LV-left ventricle, RA-right atrium, RV-right ventricle, MV-mitral valve. b: Transthoracic echocardiogram (TTE) apical view, showing the mass at the mitral valve prolapsing into the left ventricle during the diastolic cardiac cycle (arrow). Abbreviations: LA-left atrium, LV-left ventricle, RA-right atrium, RV-right ventricle, MV-mitral valve

Fig. 2

Post resection gross specimen with estimated size of 5.0 × 4.0 × 3.0 cm (ruler). Reported as 6.2 × 4.3 × 2.9 cm in the pathology report

Fig. 3

a Microscopy 10X magnification, structures of blue rings (red circle) and cords (red arrow), characteristic histologic features of myxomas. Alcian Blue Periodic Acid Schiff blue stain for mucopolysaccharide myxoid substance containing chondroitin sulfate and hyaluronic acid. b: Microscopy 20X magnification, lymphocytes (red circle), no mitotic Figs. c: Microscopy 40X magnification, hemosiderin laden macrophages (red circle), nests of myxoma cells (black circle), negative for malignancy

Fig. 4

a: Peri-operative chest xray shows “double density” behind the right heart border, a common indication of left atrial enlargement. b: Pre-operative CT chest without contrast, axial view showing limited anatomical detail. Intracardiac mass not discernable. Abbreviations: RA-right atrium, RV-right ventricle, LA-left atrium, LV-left ventricle, DA-descending aorta, L-liver. c: Pre-operative, CT chest without contrast, coronal view showing limited mediastinal detail, left atrium myxoma is not apparent or noticeable. Abbreviations: RA-right atrium, AO-Ascending aorta, PT-pulmonary trunk, LV-left ventricle

Fig. 5

a: Pre-operative Electrocardiogram showing normal sinus rhythm, no ischemic changes or ventricular hypertrophy in all leads. b: Pre-operative Electrocardiogram, enlarged view of Lead II showing P mitrale, left atrial enlargement (arrow). c: Pre-operative Electrocardiogram, Lead V1 shows and deepening of the terminal negative portion of the P wave, possible left atrial enlargement (arrow)

Fig. 6

a: Transesophageal echocardiogram midesophageal four chamber view showing a 2.3 × 1.9 × 0.5 cm tricuspid mass (arrow), during systole. Abbreviations: RA-right atrium, RV-right ventricle, LA-left atrium, LV-left ventricle, Tv-tricuspid valve. b: Transesophageal echocardiogram midesophageal four chamber view showing partial obstruction of right ventricular inflow during diastole (arrow). Abbreviations: RA-right atrium, RV-right ventricle, LA-left atrium, LV-left ventricle, Tv- tricuspid valve. c: CT chest with contrast showing contrast enhanced axial CT scan with minimal enhancement of the mass (arrow) at the level of the tricuspid valve. The radiologist reported the finding as a 2.1 cm oval fatty mass seen along the tricuspid valve. Cardiac tumors are usually low attenuating. Abbreviations: RA-right atrium, RV-right ventricle, LA-left atrium, LV-left ventricle, Ao-aorta, IVC-inferior vena cava, L-liver. d: CT chest with contrast showing contrast enhanced sagittal CT scan with minimal enhancement of the mass (arrow). Cardiac tumors are usually low attenuating. Abbreviations: RA-right atrium, RV-right ventricle, LA-left atrium, Asc Ao-ascending aorta, PA-pulmonary artery, DA-descending aorta. e: CT chest with contrast showing contrast enhanced coronal CT scan with minimal enhancement of the mass (arrow). Cardiac tumors are usually low attenuating. Abbreviations: RA-right atrium, RV-right ventricle, LA-left atrium, LV-left ventricle, PT-pulmonary trunk, AO-ascending aorta