Patient: Male, 27Final Diagnosis: Burkitt lymphoma with intracardiac massSymptoms: Dizziness • fatigue • palpitations • weight lossMedication: —Clinical Procedure: Catheter-directed thrombolytic therapy with intracardiac infusion of alteplaseSpecialty: HematologyObjective:Rare diseaseBackground:Non-neoplastic causes such as infections and thrombi account for most intracardiac masses. Primary tumors such as myxomas and metastasis from breast cancer, lung cancer, or melanomas account for many of the remaining cases. Burkitt lymphoma manifesting as an intracardiac mass is a rare entity, with 21 cases reported in the English literature.Case Report:We report the case of a man infected with human immunodeficiency virus (HIV) who presented with non-specific cardiac symptoms and was later found to have intracardiac mass caused by Burkitt lymphoma. His rapid decline with unexpected complications was reversed with prompt management. Subsequent to induction, the patient achieved a near complete response with considerable improvement in his condition.Conclusions:Lymphoma should be considered in the differential diagnosis of intracardiac masses. Associated cardiac symptoms are frequently non-specific and can often be overlooked or underappreciated. Burkitt lymphoma has a short doubling time and an intracardiac lesion can become life-threatening in a matter of days. Early recognition and prompt treatment are crucial to achieving optimal outcomes.
Learning Objectives: Introduction: Arterial air emboli as a result of venous air emboli (VAE) are a rare complication following centrally or peripherally inserted central catheters (PICC). Case Description: A 79yo female with history of CAD was admitted for a post-operative hip infection, and was undergoing PICC placement for long-term antibiotic use. Post-procedure the patient was unresponsive, hypoxic, and rigid, with clenched fists and left lateral conjugate gaze. Despite assisted respirations with bag ventilation mask, the patient required intubation. Once stabilized, a head CT was performed and demonstrated gas bubbles in both cerebral hemispheres. The patient remained poorly responsive and a STAT EEG was performed which demonstrated epileptiform activity. A head CT the next morning demonstrated resolution of gas bubbles. An echocardiogram, to evaluate for stroke symptoms, displayed a significant right to left shunt within the atria. An MRI demonstrated ischemic changes within the right frontal, parietal, and left temporal regions, which correlate directly with areas of prior gas visualization. The patient failed to recover neurologically and the family withdrew care. Discussion: The patient's clinical scenario and imaging support cerebral air emboli (CAE) resulting from venous air entering circulation during PICC insterion, and into aterial circulation via an atrial defect. The incidence of CAE is estimated to be 0.13% during insterion/removal of central venous catheters. CAE causes ischemia and inflammation, resulting in decreased cerebral perfusion and neurologic impairment. Morbidity and mortality of air emboli depend on the rate and volume of gas entering venous circulation and the organ affected. Catheterassociated VAE carry a mortality rate between 23-30%. As little as 20mL of cerebral air has been reported to cause clinical harm, but traditionally 5 mL/kg is required to cause mortality. Treatment of CAE is supportive, with maintenance of adequate oxygenation and hemodynamic stability. High-flow and hyperbaric oxygen are reported to improve resorption of air.
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