A 69‐year‐old man presented with 1 week of shortness of breath associated with lower‐extremity and scrotal edema. He had elevated JVP and distended external jugular veins, an enlarged liver, and bilateral leg edema. Lung sounds were diminished at bases. White blood count was normal. Hemoglobin was 11.6 g/dL and creatinine was 3.1 mg/dL Total protein was 8.5 g/dL and albumin was 3.2g/dL EKG was normal sinus rhythm, but his ER course was notable for having 3 asymptomatic episodes of supraventricular tachycardia with a rate in the 160s. Echocardiogram demonstrated a right atrial mass measuring 6 × 3 cm with compression of the right main‐stem bronchus. Serum protein electrophoresis was positive for an M‐spike, and bone marrow biopsy showed 50% plasma cells. The patient was diagnosed with multiple myeloma, and the intracardiac mass was presumed to be an extramedullary plasmacytoma, a rare cause of intracardiac mass. The patient's symptoms improved with diuresis, but he continued to have episodes of SVT, thought to be due to mechanical irritation from the plasmacytoma in his right atrium. He was started on diltiazem, bortezomib, dexamethasone, and after 16 days in the hospital he was discharged home. Six days later he was found unresponsive and pulseless on the floor of his home after his family heard him collapse. EMS provided care, and with ACLS the patient regained a pulse, but he coded twice more after arrival in the hospital. His family changed his code status to DNR, and he passed away within 24 hours of readmission. Autopsy was declined by the family.
The presentation and differential of intracardiac mass is a topic of importance for the hospitalist, who is likely to be the first‐line provider at the time of diagnosis. Primary tumors of the heart are rare. Cardiac myxoma is the most common benign cardiac tumor, whereas cardiac sarcoma is the most common primary cardiac malignancy. More common than primary cardiac tumors, however, is metastatic disease. Metastatic disease from lung cancer, lymphoma, and breast cancer are among the most common types of cancers at autopsy studies to demonstrate cardiac metastasis. Melanoma relatively frequently metastasizes to the heart, but due to the relative rarity of melanoma compared with other types of cancer, this metastatic presentation is less frequently found. Multiple myeloma has also been found to metastasize to the heart with prior cases confirming the diagnosis at autopsy or through biopsy samples.
Both benign and malignant cardiac tumors, whether primary or metastatic, can lead to further complications due to arrhythmias, obstruction of blood flow, and embolization.
To cite this abstract:Sharma P. A Rare and Fatal Case of Shortness of Breath. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 324. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-rare-and-fatal-case-of-shortness-of-breath/. Accessed April 2, 2020.