Coronary vessel floating sign and vasospastic angina in a patient with cardiac lymphoma

Akio Chikata, Satoru Sakagami, Naomi Kanamori, Chieko Kato, Wataru Omi, Takahiro Saeki, Hideo Nagai, Atsuhiro Kawashima, Soichiro Usui, Masayuki Takamura
2014 International Journal of Cardiology  
A 59-year-old immunocompetent man was referred to our emergency room with syncope. The patient's Glasgow Coma Scale was E4V5M6, and neurological examination revealed no palsy. He reported no history of trauma or prescribed medication use, and his vital signs were as follows: body temperature, 37.3°C; blood pressure, 104/74 mm Hg, pulse rate, 30 beats per minute (bpm) with irregular rhythm; and oxygen saturation in room air, 100%. Physical examination revealed distention of the jugular vein in
more » ... e sitting position. On auscultation, his lung sounds were normal, and the pericardial friction rub was not clearly heard. Lower leg edema was not evident. Chest X-ray revealed cardiomegaly without pulmonary congestion. Electrocardiography (ECG; 12-lead) showed atrial fibrillation with bradycardia and ST elevation in the inferior leads. Soon after admission, atrial fibrillation spontaneously restored to sinus rhythm, and ST elevation also improved ( Fig. 1A and B) . Emergency coronary angiography revealed no significant stenosis ( Fig. 2A and B ; see Supplementary Videos 1 and 2). We suspected vasospastic angina (VSA) because of ST elevation without coronary artery stenosis. Laboratory findings were as follows: white blood cell count, 11,400 mm 3 ; C-reactive protein, 3.9 mg/dL; procalcitonin, 0.06 ng/mL; creatine phosphokinase, 165 IU/L; troponin T, negative; and brain natriuretic peptide, 15.7 pg/mL. Thyroid function was normal and antinuclear antibody was negative. The lactate dehydrogenase (LDH) level was slightly elevated (422 IU/L), the serum soluble interleukin-2 receptor (sIL2R) level was within normal limits (445 U/mL). Paradoxical pulse became overt in sinus rhythm. Transthoracic echocardiography revealed circumferential pericardial fluid retention ( Fig. 3 and Supplementary Video 3). Pericardiocentesis yielded 1 L of bloody pericardial fluid containing an extremely high LDH (7752 IU/L) level. Cytological examination of pericardiocentesis fluid revealed numerous mid-to large-sized atypical lymphoid cells with prominent nucleoli. Subsequent ECGgated, contrast-enhanced multidetector row computed tomography (MDCT) revealed a mass located around the atrioventricular (AV) groove and encasing the right coronary artery (RCA) without arterial invasion or compression (vessel floating sign; Fig. 4A-D) . The tumor extended to the inferoposterior wall of the left ventricle (LV) along the RCA (Fig. 4E and F). Abnormal accumulation was observed at the same site on a gallium 67 scan. Immunohistochemical analysis of the cell block section of the effusion showed that the lymphoid cells were positive for CD20, with a high MIB-1 index, and negative for CD3.
doi:10.1016/j.ijcard.2014.06.081 pmid:25049011 fatcat:uepkttoaj5dyzgau3fce3efsiy