Thank you to Ashley S.M. for presenting a really fascinating case from the ICU. We talked about a middle aged man with HIV/AIDS off ARVS, who presented with DOE, found to have multiple atrial masses and tamponade, ultimately d/t an infiltrative cardiac lymphoma (path pending).
We talked about this case at two reports, so here are the combo of learning points!
Approach to Atrial Masses
Masses in the heart can have hemodynamically significant effects on circulation, valve function, and risk for embolization.
Ask yourself 1) is this a real mass or is it actually just a clot? 2) if a mass, is it benign or malignant? 3) for malignant masses, consider both primary neoplasm and metastatic disease. Overall, the most common cause of an atrial mass is a benign atrial myxoma. See the attached table below, but important malignant causes to consider are sarcoma, lymphoma and metastatic tumors. Given his HIV/AIDS, our infectious differential also included
- Infective endocarditis with large valvular veg or very large perivalvular abscess
- TB endocarditis (usually more pericardial involvement)
- Endemic fungal disease: especially in CA, consider cocci for cardiac involvement
HIV associated malignancies: Monica Gandhi helped share a useful framework about thinking about the three main oncogenic viruses that cause malignancy in pts with HIV. For all of these malignancies, also critically important to start ARVs right away!
- Cervical / anal / head and neck squamous cell cancers: HIV infected patients are less able to clear oncogenic strains of HPV. The incidence of cervical dyplasia (CIN) in patients with HIV is 4-5x higher than in patients without HIV.
- EBV : highly associated with Burkitt’s and DLBLC. Remember that these lymphomas can be exquisitiely responsive to chemotherapy so it is important to start treatment right away.
- Burkitt’s Lymphoma
- Kaposis Sarcoma
- Castlemans disease (multicentric form)
- Primary Effusion Lymphoma
Burke A, Jeudy J, Virmani R. Cardiac tumours: an update. Heart 2008;94:117-123. http://heart.bmj.com/content/heartjnl/94/1/117.full.pdf