A woman with dyspnea and hemoptysis.

A 55-year-old female presented to the emergency department at a small community hospital with cough, fever, dyspnea and blood-streaked sputum. A chest radiograph was ordered. She was diagnosed with pneumonia and discharged home with antibiotics. She returned three days later, afebrile, with worsening dyspnea and gross hemoptysis. She was found to have a murmur reported as chronic but had never been evaluated by echocardiography. A computed tomography chest and echocardiography were performed (Figure). She was diagnosed with a left atrial myxoma (Video). She was transferred and underwent tumor excision.

DISCUSSION

Primary cardiac tumors are rare with an incidence of 0.05%.1 The overwhelming majority of cardiac myxomas are located in the left atrium, followed by the right atrium and then in the ventricles.2,3 Like most cardiac myxomas, the histology in this presentation is benign. The myxoma triad consists of obstructive symptoms (heart failure, shortness of breath), malaise, and embolic events. Physical exam may reveal a murmur known as “tumor plop” that often mimics mitral stenosis.4 The diagnosis is often made when evaluating for etiologies of similar presentation. Echocardiography, chest computed tomography (CT), cardiac magnetic resonance imaging (MRI), and cardiac angiography have all been described. Echocardiography has the advantage of being able to evaluate size, shape, location and mobility in a dynamic fashion with reported sensitivities of 95% and nearly 100% for transthoracic and transesophageal, respectively.5 MRI and CT appear to have lesser reliability when determining tumor origin.6 The prognosis is good with a 96% 10-year survival rate.3