Title

Faint of Heart and a Myxoma

Authors

Manisha Koneru, MS; Kyle Gleaves, MD; Satyajeet Roy, MD, FACP

Cooper Medical School of Rowan University

Introduction

The differential for syncope is broad, and consequently can pose a diagnostic challenge. Co-presenting atypical symptoms warrant further clinical investigation to identify potentially life-threatening etiologies.

Case Presentation

A 74-year-old woman with a history of asthma, hyperlipidemia, and hypertension was singing in a choir when she developed epigastric cramping followed by fainting. As per the witnesses, her eyes had rolled back into her head prior to the presentation. She regained consciousness within a few seconds, but was noted to be confused and diaphoretic immediately afterward. She returned to her baseline within a few minutes. One week prior, she reported having an episode of vertigo followed by a sensation of fullness and decreased hearing in one ear. She endorsed continued lightheadedness, but denied fever, chest pain, palpitations, nausea, or shortness of breath. Her physical exam was remarkable for elevated blood pressure of 152/100 mmHg, erythematous and injected appearance of the right tympanic membrane, and negative Dix-Hallpike maneuver. Other physical findings were within normal limits. Her electrocardiogram (ECG) showed normal sinus rhythm without other acute abnormalities. Prior episode of vertigo was thought to be likely secondary to acute otitis media. Despite normal ECG, associated epigastric symptoms prompted further screening to rule out cardiac etiology prior to favoring orthostatic or vasovagal causes of syncope. Her chest X-ray was unremarkable. A transthoracic echocardiogram demonstrated a 2x2.3 cm, non-mobile, heterogeneous mass in the left atrium originating from the interatrial septum, concerning for myxoma. The mass was excised. Surgical pathology confirmed a diagnosis of atrial myxoma (AM). Postoperative course was complicated by development of tachycardia-bradycardia syndrome, requiring pacemaker placement. Subsequently she remained asymptomatic on amiodarone, metoprolol, furosemide, and apixaban.

Discussion

AM is a benign cardiac mass. Approximately 50% of cardiac tumors are AM, and they are estimated to occur in <1% of the population. Definitive diagnosis is primarily through gross and microscopic pathology; thus, most confirmed diagnoses occur with surgical pathology or autopsy. Surgical excision is definitive treatment. Clinical manifestations of AM depend on its size, and can range from asymptomatic to moderate, nonspecific obstructive cardiopulmonary symptoms to sudden death. Consequently, AM poses a diagnostic challenge given its nonspecific presentation in the context of the larger scope of differential diagnosis for syncope. The differential for syncope includes vasovagal, cardiogenic, orthostatic, neurologic, endocrinologic, and psychiatric causes. In patients presenting atypically, such as with epigastric symptoms, further cardiogenic workup is warranted to identify potentially life-threatening causes before favoring other, more conservative diagnoses.

In conclusion, investigation of syncope presenting with atypical epigastric cramping should include diagnostic testing to rule out potentially life-threatening cardiac etiology. AM is a rare, benign cardiac tumor which is usually asymptomatic, but has risk to precipitate fatality. The infrequency of occurrence of AM and nonspecific stigmata presents a diagnostic challenge.

References

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