Extensive myocardial infiltration by hemopoietic precursors in a patient with myelodysplastic syndrome

Abstract

BackgroundAlthough myocardial infiltration with leukemic blasts is a known finding in patients with acute leukemia, this phenomenon in myelodysplasia is not reported in the literature. Cardiac symptoms in patients with myelodysplasia are often due to anemia and may be due to iron overload and side effects of therapy.Case presentationHerein we report the first case of neoplastic infiltration of the heart with associated myocardial necrosis in a patient with myelodysplasia. It was associated with unicellular and multifocal geographic areas of necrosis in the left ventricle and the interventricular septum. It is likely that cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks and myocardial necrosis. Myocardial necrosis was most likely due to a combination of ischemic damage secondary to anemia and prolonged hypotension and extensive leukemic infiltration. Markedly rapid decrease in ejection fraction from 66% to 33% also suggests the role of ischemia, since leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period. The diagnosis was not suspected during life due to concomitant signs and symptoms of anemia, pulmonary infections, and pericardial and pleural effusions. The patient succumbed to cardiac failure.ConclusionHemopoietic cell infiltration was not considered in the differential diagnosis and contributed to this patient's morbidity and mortality. This case highlights the clinical importance of considering myocardial infiltration in patients with myelodysplasia and cardiac symptoms.

Therapy-related myelodysplastic syndrome presenting as fulminant heart failure secondary to myeloid sarcoma

“…Rarely leukemic infiltration causes complete heart block, which can resolve once the tumor is treated [10]. A similar case in a patient with myelodysplatic syndrome was reported by Mateen et al [18], with extensive myocardial infiltration by hematopoietic precursors. In our patient, we preferred to use the term myeloid sarcoma since we found leukemic cells diffusely infiltrating the entire heart and markedly effacing the myocardium, despite the lack of a focal, discrete tumor mass.…”

“…It can also be the first manifestation of blastic transformation in patients with chronic myeloproliferative disorders or myelodysplastic syndrome, or can present as relapse in patients previously treated for leukemia. Although myeloid sarcoma has been reported in almost every site of the body, cardiac involvement is unusual [4,7,[9][10][11][12][13][14][15][16][17][18]. We report the case of a 59-year-old man with a history of t-MDS who died of rapidly progressive heart failure.…”

“…The diagnosis was unexpected given the diagnosis of t-MDS, but no evidence of acute leukemia in the blood or bone marrow and the lack of a distinct cardiac mass on transesophageal echocardiography. The development of cardiac myeloid sarcoma in patients with myelodysplastic syndrome is extremely rare [5,6,18]. The reason for the patient's fulminant course and rapid deterioration in cardiac function is unclear.…”

Cardiac ALL: Most Unusual Occurrence of Lenalidomide-associated Acute Lymphoblastic Leukemia with Subsequent Cardiac Involvement

“…In a 20-year autopsy study, cardiac metastases comprised only 1.2% of all cases of metastasis, amongst which leukemia constituted only 4% [7]. Cardiac involvement is commonly seen when the peripheral blast count is elevated and with advanced disease [8], but the presence of a high blast count is not always present when developing cardiac/tissue infiltration [9]. The clinical picture is variable, with the majority of patients being completely asymptomatic but others can present with chest pain, dyspnea, congestive heart failure, arrhythmia, ST-elevation, pericardial effusion, and tamponade [2,10].…”

Bradycardia following retinoic acid differentiation syndrome in a patient with acute promyelocytic leukaemia

“…In a series of postmortem examinations in patients with relapsed AML, microscopic blast infiltration of the myocardium was a frequent discovery,14 but the clinical significance of this finding is unclear 15. Heart block has been reported in AML which responded to radiotherapy16 and has also been reported in a patient with myelodysplasia with acute pericardial effusion in the context of likely transformation to AML; with myeloid infiltrate in the myocardium at postmortem 17. In addition, a patient with relapsed acute lymphoblastic leukaemia died from ventricular fibrillation due to prominent myocardial infiltrate on echocardiography 18…”