case_images: PMC9836803_01
case_images: Transthoracic echocardiogram. Apical four chamber view demonstrating a large right atrial mass (arrow) causing tricuspid valve obstruction with associated pericardial effusion (asterisk). Abbreviations: RA (right atrium), RV (right ventricle), LV (left ventricle), and LA (left atrium).
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case_images: PMC9836803_01_CRIHEM2023-5501131.001.jpg
case_images: fig1
case_images: The transthoracic echocardiogram (TTE) confirmed a large right atrial mass extending into the right ventricle and origin of the inferior vena cava resulting in severe tricuspid obstruction and RV dilatation, with an associated 1.9 cm pericardial effusion without signs of tamponade (Figure 1).
case_images: Trend of platelet count in units 109/L throughout treatment.
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case_images: fig2
case_images: This was further complicated by the development of ischaemic hepatitis with an associated coagulopathy (PT 50 s, INR 4.4, APTT 34.5 s, fibrinogen 3.0 g/L, and D-dimer 3.49 mg/L) and worsening thrombocytopenia to a nadir of 18 x 109/L on day 10 of admission, clinically manifesting with recurrent epistaxis and haematuria (Figure 2). His platelet count normalised to 154 x 109/L after two cycles of half-dose R-CHOP and has remained normal (Figure 2).
case_images: Endomyocardial biopsy. Hematoxylin and eosin staining ((a) x10 magnification and (b) high power view) demonstrates atypical large lymphocytes confirmed as B-cells on Pax5 immunohistochemistry (c). Ki67 stain (d) demonstrates a high proliferation rate.
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case_images: fig3
case_images: Endomyocardial biopsy of this mass confirmed large atypical lymphocytes staining positive for CD20, bcl-2, bcl-6, and c-myc consistent with an aggressive B-cell lymphoma (Figure 3).
case_images: Initial PET (a) demonstrates focal intense FDG uptake corresponding to a right sided cardiac mass (SUVmax 20.6), no longer evident on progress PET (b) in keeping with complete metabolic response. There is moderate physiological uptake in the left ventricular myocardium seen in (b).
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case_images: fig4
case_images: Positron emission tomography (PET) revealed focal intense FDG uptake in the right atrial mass with no evidence of any other metabolically active nodal or extranodal disease, consistent with a diagnosis of primary cardiac lymphoma (Figure 4).