Syncope: Sometimes you just have to think outside the box
This not your average syncope: A rare case of Non-Hodgkin’s lymphoma with cardiac involvement.
Syncope usually has a broad differential diagnosis which most of the time gets to be evaluated by a general cardiologist. The common causes of syncope which usually involves a comprehensive cardiovascular care are severe aortic stenosis and arrhythmias. The patient whom we will be talking about did not meet any of the aforementioned conditions.
This is story is about a 89-year female with cardiovascular comorbidities such hyperlipidemia and hypertension, other medical conditions such hypothyroidism. She has had multiple syncope within the past year. She finally decided to present to the emergency department because she started feeling fatigued, headaches and generalized malaise. Nowadays CODID-19 is always part of the differential. Once ruled out, the common work up for syncope were pursued including an echocardiogram which revealed a large mass into the right chambers concerning for a malignant process. Further work up with Cardiac MRI was performed to better characterize the echocardiographic findings and revealed a large oval-shaped infiltrating mass invading the right atrium, the right ventricle and leading to tricuspid stenosis and low forward flow explaining her recurrent syncope. The mass caused a shift in hemodynamics which explains the patient’s syncope. Our approach to management was not straight forward initially as he could plan to excise it although not knowing was it actually is might further complicate things. Therefore, a right ventricle biopsy was performed, and pathology confirmed the diagnosis of aggressive double expresser B-cell non-Hodgkin’s lymphoma at which point it was decided to treat with chemotherapy with subsequent response including initial shrinking of the mass and no further syncopal event. Our patient’s case is an example how everything in medicine is not textbook and further thinking outside the box is different between life and death. We were able to treat the patient’s illness without hving her undergo invasive cardiac surgery.
Garly St-Croix MD, Michel Ibrahim MD
