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- Cardiothoracic surgery
- Respiratory medicine
- Radiology (diagnostics)
- Surgical diagnostic tests
- Cardiovascular medicine
Description
A man in his early 40s was referred to the respiratory outpatient department by his general practitioner (GP), with a history of breathlessness on exertion. The referral was triggered when the patient described symptoms suggestive of haemoptysis.
At the respiratory clinic, the patient described how he had deteriorated over the preceding 6–12 months. From a very fit baseline, he now reported increasing dyspnoea while running and during exercise classes, although he was still able to complete his workouts. His GP had become concerned about a respiratory pathology when the patient reported ongoing exertional dyspnoea and an occasional taste of blood in his mouth. In total he had experienced this taste of blood in his mouth on three occasions. He had an intermittent cough productive of pink sputum and a postnasal drip. He had quit smoking 7 years previously but continued to vape occasionally.
The physical examination of the cardiac and respiratory systems was unremarkable. He had normal breath sounds throughout all lung zones and normal heart sounds with no added murmurs. He had no hand signs or peripheral stigmata of respiratory or cardiac disease. The only minor finding of note was slightly inflamed nasal mucosa. Surprisingly, he did not have any audible tumour plop, which would have been expected given the size of the tumour subsequently diagnosed, and the proximity to the mitral valve.
Prior to referral to the respiratory clinic, a chest X-ray and physician supervised exercise stress test had been performed. Both were reported as normal.
Given the inflamed nasal mucosa, progressive dyspnoea, postnasal drip and symptoms suggestive of haemoptysis, a total immunoglobulin E (IgE) level and immunoassay to common allergens were sent and he was trialled on a steroid nasal spray while an outpatient CT thorax and bronchoscopy were awaited. The total IgE level and immunoassay were normal. He did not experience any substantial improvement in symptoms after starting the nasal spray.
On the day of the bronchoscopy, the CT was also performed and showed a massive left atrial mass (figure 1), filling almost the entirety of the left atrium and protruding into the mitral valve. This was better visualised on echocardiography (figure 2 and video 1) performed emergently on the same day. He proceeded to emergency excision of the mass and recovered well postoperatively. Histopathological analysis confirmed features of an atrial myxoma.
CT scan of the thorax showing large left atrial mass.
Transthoracic echocardiography image showing left atrial myxoma occupying almost all of the left atrium.
This case demonstrated that even the largest of atrial myxomas can go undiagnosed for a significant length of time as the symptom burden may not correlate with tumour size. In cases of persistent, unexplained dyspnoea, an atrial myxoma should be considered1 2 and appropriate investigation with echocardiography should be arranged promptly.3 The case also demonstrates the overlap in clinical presentation between respiratory and cardiac pathologies and the importance of considering this when planning investigations.
Patient’s perspective
The breathlessness from exertion was probably first noticed by me about 13 months before diagnosis of the myxoma, and I first went to the GP about a month or 6 weeks later. In that time, I probably attended my GP on about four different occasions. I told my GP I didn’t think I was quite as strong exercising as I used to be. After initial examination and a blood test, my GP thought it might be due to a lack of iron and mild anaemia.
The next time I visited my GP when my symptoms continued, he sent me for a treadmill stress test. After the stress test, the doctors examining me believed my heart was normal.
It was after this and suggesting again that I might have coughed or tasted blood again after exercising that the GP sent me for a chest X-ray, which was clear.
I still felt something was wrong and after tasting blood again and pink spit after exercising, my GP sent me to a lung specialist which led to a CT and bronchoscopy.
The only reason I pursued the issue is because I noticed it on exertion. I had a fairly decent level of aerobic fitness and used to exercise a couple of times per week. Day to day, I did not really have any other symptoms, although I do remember saying that running up a flight of stairs, I thought I felt a palpitation afterwards.
I think if I wasn't exercising, I probably wouldn't have noticed I had any issue.
Learning points
Diagnostic investigations arising from ‘red-flag’ symptoms sometimes uncover other unexpected diagnoses.
The size of an atrial myxoma may not correlate with the level of symptomatology and dyspnoea is the most common presenting symptom.
The value of echocardiography in the assessment of persistent, unexplained dyspnoea on exertion.
There can be a significant overlap in symptomatology between respiratory and cardiac pathologies as is evidenced by the presenting complaint in this case.
Ethics statements
Patient consent for publication
Footnotes
Twitter @ArtKelleher
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: ABK, TMO’C, CV and TND. The following authors gave final approval of the manuscript: ABK, TMO’C and TND.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.