Title : Unusual intracardiac mass beyond common sense
Intracardiac mass is relatively rare compared to in other organs. The nature of the mass directly determines the treatment plan and prognosis of patients. Generally speaking, it is not difficult for doctors to differentiate between tumour mass and intracardiac thrombus. Atrial thrombosis is more common in severe mitral stenosis. Ventricular thrombosis is often seen in ventricular aneurysm after myocardial infarction, and in patients with severe systolic dysfunction. We report two cases of unusual intracardiac thrombosis. One case was an 8-year-old boy with cough and fever for 13 days. A diagnosis of mycoplasma pneumonia was made based on laboratory test. A solid mass attached to chordae of tricuspid valve in RV was found from an otherwise normal echo study. The mass didn’t resolve after experimental thrombolytic treatment. Cardiac tumor was suspected and operation was successfully performed to remove it. Pathology diagnosis turned out to be a thrombus. The other case was a 34-year-old female with a history of dizziness, drowsiness and confusion for 3 days. MRI showed subacute multiple cerebral infarction. Echo study showed: cardiomegaly, LVEF18% and apical thrombus. She was originally diagnosed as dilated cardiomyopathy with left ventricular apical thrombosis, but laboratory test showed positive lupus anticoagulant test and dramatic changes within 3 months after treatment offered clue for other diagnosis. A possible antiphospholipid syndrome made the unusual clinical scenario more reasonable.
Audience take away:
- Some special infection, especially mycoplasma pneumonia, may trigger the auto immune system, which can make intracardiac thrombosis happen even in a heart with normal size and normal systolic function. Doctors should be aware of cardiac thrombosis possibility and associate laboratory tests should be included in such situation. Transient autoimmune antibodies, especially antiphospholipid antibodies, are associated with increased risk of a/v thrombosis.
- Antiphospholipid syndrome (APS) is a systemic autoimmune disease defined by thrombotic or obstetrical events that occur in patients with persistent antiphospholipid antibodies. Vascular thrombosis can be documented as one or more episodes of arterial, venous or small vessel thrombosis in any tissue. Dilated cardiomyopathy like condition is a rare cardiac manifestation of APS.
- Dramatic response to anticoagulants, steroids can be observed in severe APS cases. This helps to differentiate APS to common dilated cardiomyopathy.
- In patients with obstetrical and thrombotic events APS is often easily of concern. However it is often ignored and underdiagnosed in dilated cardiomyopathy like condition with intracardiac thrombosis.
- Lessons learned from these cases would help cardiologists to achieve early correct diagnosis and better outcome of the patients.