BRIEF HISTORY
A 35-year-old man presented to the cardiology outpatient with a history of fever, malaise and palpitations for the last four months. The fever was low grade and intermittent in character. On one
occasion, he developed sudden pain in the left leg which became pale, cold and heavy. Two weeks prior to his recent visit to the hospital, he had a syncopal attack and recovered spontaneously.
There was no history of chest pain but occasionally he had dyspnoea on exertion.
IMPORTANT CLUES ON CLINICAL EXAMINATION
On examination, he looked pale and a bit anxious. Temperature was 99.4 ° F. General physical examination was normal. Pulse was 96 per min, regular and good volume with all peripheral pulses
palpable. BP was 130/85 mm Hg. First heart sound was split with accentuation of the pulmonic component of second heart sound and mid-diastolic murmur at mitral area. Chest examination
revealed bilateral basal crackles. Abdominal and neurological systems were normal.
INVESTIGATIONS
Investigations included:
QUESTIONS
Q.1. What is the diagnosis?
Q.2. What further investigations would you ask for?
Q.3. What happens to the immuno-electrophoretic pattern in
this condition?
Q.4. Give a brief account about this condition.
Q.5. What is the treatment?
Medicine
A.1.
In a person who had history of low grade fever, weight loss, occlusion of an artery (left lower limb), a syncopal attack and raised ESR point towards a diagnosis of left atrial myxoma. Presence of murmur makes it more probable.
A.2.
Echocardiogram is characteristic in this case. There is persistent uniform echogenicity behind the anterior mitral valve leaflet if the myxoma is protruding in the mitral valve area on M-mode while on two-dimensional view, the myxoma is visible in the left atrium.
A.3.
There is increase in IgG fraction of gamma globulins.
A.4.
Although these are rare primary tumours of the heart, but they are potentially curable. They occur most frequently in the atria, and left atrium is involved three times more than the right atrium. They may be unilateral or bilateral and are often pedunculated, while if they are present in the ventricles, they are sessile. The symptoms result from impediment to blood flow through the heart, embolization from the tumour in the systemic or pulmonary beds and generalised constitutional abnormalities. Left atrial myxomas mimic mitral stenosis or regurgitation and their sequelae, while right atrial myxoma presents as tricuspid stenosis.
A.5.
It is surgical resection of the tumour which results in complete cure, including relief of the constitutional symptoms. Because of the potential for recurrence, the endocardial attachment should be excised. Follow-up echocardiography is required afterwards.
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