Quick Fire Cases
Leonela Bastidas, MD
Resident Physician
St Luke's Hospital
Leonela Bastidas, MD
Resident Physician
St Luke's Hospital
Shane Larue, MD
Cardiologist
St. Luke's Hospital
Mark Fesler, MD
Hematology Oncology
St Luke's Hospital
Anupama Rao, MD, FACC, FSCMR
Physician, Associate Professor of Medicine
Rush University Medical Center/St. Luke's Hospital
We present a case of a 73-year-old female with a known history of diffuse large B-cell lymphoma who presented to an outside Emergency Department with severe headaches, neck pain, confusion, ocular redness, monocular diplopia, and photophobia for over a week. A CT head without contrast was obtained and was unrevealing. A CT angiography revealed moderate size pericardial effusion. Due to concerns about lymphoma relapse, she was transferred to our institution, where she receives her oncologic care. She denied chest pain, lower extremity edema, orthopnea, or paroxysmal nocturnal dyspnea. Vital signs were stable. Her physical exam was unremarkable. NTproBNP was elevated.
Diagnostic Techniques and Their Most Important Findings:
A transthoracic echocardiogram revealed a homogeneous mass adherent to the RV-free wall. A cardiac MRI followed, revealing the complex, ill-defined mass in the anterior pericardium adjacent to the left ventricular apex and right ventricular outflow tract, infiltrating the right ventricular myocardium. On LGE imaging, there was patchy enhancement of the RV-free wall and outflow tract. The overall findings were suggestive of lymphomatous infiltration.
An MRI of the brain revealed orbital lymphoma. Her presentation and findings are suggestive of disseminated lymphoma with cranial neuropathy and cardiac involvement. Management considerations include chemotherapy and possible surgical intervention.
Learning Points from this Case:
Cardiac involvement from diffuse large B-cell lymphoma is rare. The incidence is generally reported to be between 0.5% and 2% of cases in clinical practice, though some autopsy studies suggest that the rate of subclinical involvement could be higher, approaching 20-30%. Cardiac involvement represents a late manifestation of disseminated lymphoma. The most involved site is the pericardium (41.1%), followed by the right-sided chambers (34.8%). Frequently, cardiac involvement is discovered incidentally or at autopsy, as it is often asymptomatic.
TTE is the screening modality of choice, with a sensitivity of 60%. However, CMRI is an invaluable tool for assessing lymphomatous infiltration of the heart, offering detailed tissue characterization, functional assessment, and the ability to monitor treatment response—all without the need for invasive procedures.
