Here's a Surprise
Christmas is coming and we all like surprises. But that's not true of the patient I will present to you today. Read on and find out why.
The story of Eva
Eva was a very active lady and had never been seriously ill. However, she had been feeling unwell for a few months now: headaches, pain in the joints, malaise, and fatigue. Eva went to the doctor, but nothing was found. Her lab values were normal - no sign of infection. The chest x ray, and even gastroscopy and colonoscopy were normal. The only notable feature was a faint murmur. Her doctor thought she might have endocarditis. That was the reason why she was sent to our lab.
Another unnecessary referral?
All of you who work in a setting where you are flooded with patients are quite familiar with this situation: a patient is referred to you and you don’t think the exam is really necessary. After all, we could not confirm the murmur and the patient did not have the slightest sign of infection. In fact, I have never seen a patient with endocarditis who does not have at least elevated CRP of white blood count - except perhaps for marantic patients. But this patient was well nourished and looked quite healthy. What should we do? We thought we would simply do the exam and get it over with instead of engaging in a long discussion with the referring physician.
And we were glad we did. Because here is what we found:
Parasternal long-axis view: can you see what is wrong?
The parasternal long-axis view showed the key finding: a mass
in the left atrium.
Four-chamber view: the mass is attached to the interatrial
The mass was approximately 2x2 cm in size, moderately mobile, and attached to the interatrial septum. I'm sure those of you who are experienced in echocardiography suspect the diagnosis.
What is it?
Before I give you the correct answer, let us take a closer look at the mass:
The mass is rather dense and its surface is smooth. Of course we cannot investigate the mass histologically, but its location and appearance are so typical that there is almost no doubt of it being a myxoma. To put it more accurately, a “smooth-surfaced” myxoma. Myxomas are the most common benign tumors of the heart. Although they may be found in all chambers and even on heart valves, the left atrium is by far the most common site. Usually they adhere to the interatrial septum via a vascular stem. Myxomas can be quite large; they may nearly fill the entire left atrium or even obstruct mitral inflow.
Fortunately this was not the case in Eva. Does it have something to do with her symptoms? Possibly. Patients with myxomas may present with symptoms similar to hers caused by microembolization. To find out, we will have to wait until the myxoma is removed.
If you want to become a true expert on tumors and masses, please check out our Masterclass. There you'll learn everything you need to know in order to really speed up your echo skills.
all the best,