Point of care ultrasound facilitated diagnosis of right ventricular mass as the etiology of syncope; A case report of intravenous leiomyomatosis

Abstract

Syncope is a common emergency department (ED) chief complaint. Rarely, syncope can be the result of right ventricular outflow obstruction from an intracardiac tumor, such as an intracardiac extension of intravenous leiomyomatosis (IVL). Typically, this type of tumor is confined to the pelvic veins, but in very rare cases, it can extend through the inferior vena cava into the right atrium. Point-of-care ultrasound (POCUS) can be a crucial tool in the ED for identifying intracardiac tumors presenting as syncope and expediting clinical management. We present the case of a 39-year-old female with no prior medical history that presented to the ED having experienced dyspnea on exertion and two syncopal episodes prior to ED admission. POCUS use in the ED elucidated the presence of a right atrial mass and further imaging showed a mass on the patient's uterus. After surgical removal of a portion of the atrial mass, a subsequent biopsy revealed it had leiomyoma-like features; as such, the patient was diagnosed with IVL. This case illustrates the importance of using POCUS in the ED to help determine the etiology of syncope. Although intracardiac extensions of IVL are rare, it is important for emergency physicians to keep this diagnosis in the differential in patients with symptoms or risk factors suggestive of IVL with intracardiac extension.

Keywords: Intracardiac tumors; Intravenous leiomyomatosis; Point-of-care ultrasound; Syncope differential; Syncope etiology.

Fig. 1

Point-of-care ultrasound showing right atrial mass as a result of an intracardiac extension of intravenous leiomyomatosis.

Fig. 2

CT chest with intravenous contrast pulmonary embolism protocol. (A) Sagittal images. (B) Coronal images. (C) Axial images. Red arrows demonstrate the atrial filling defect/hypoattenuation, concerning for mass or thrombus. Blue arrow demonstrates pulmonary filling defect, subsegmental in the left lower lobe. (Color version of this figure is available online.)

Fig. 3

MRI heart without contrast. (A) Axial image. Red arrow demonstrates mass prolapsing into the right ventricle. (B) Sagittal image. Red arrow indicates thrombus. Blue arrow indicates extension to the inferior vena cava. (Color version of this figure is available online.)

Fig. 4

CT abdomen and pelvis with and without contrast. (A) Coronal image of the abdomen and pelvis. (B) Axial image of the pelvis. Red Arrows indicate a large, heterogeneous cystic and solid mass emanating from the posterior uterine body extending cranially to the L3-4 level. Size is approximately 10.3 × 17.3 × 10.4 cm. (Color version of this figure is available online.)