A Right Atrial Mass Associated With Cytology-Negative Hemopericardium in a Patient With HIV

A 51-year-old African-American man, recently diagnosed with human immunodeficiency virus (HIV) and preserved CD4 count, presented to an outside hospital with 1 month of progressive exertional dyspnea associated with dry cough for the past 2 weeks. Computed tomography (CT) of the chest was remarkable for a large pericardial effusion as well as small pleural effusions and pulmonary nodules. Cardiac tamponade was noted to develop subacutely; however, this was promptly and successfully managed by fluoroscopic-guided pericardiocentesis. A sample of bloody pericardial fluid was obtained and sent to the laboratory for analysis. The etiology of the effusion was inconclusive given laboratory results, which included negative cytology. Ultrasound-guided thoracentesis of his pleural effusion was later performed, but this too was notable for negative cytology in an otherwise exudative fluid sample. Positron emission tomography-CT (PET-CT) with fluorodeoxyglucose (FDG) showed hypermetabolic uptake in the right atrium, suggestive of malignancy (Figures 1-2). Cardiac CT (Figure 3) and cardiac magnetic resonance imaging (MRI) (Figure 4) revealed a large, low-density mass in the right atrium with no extracardiac extension.

Figure 1: Coronal PET-CT

Figure 1

Figure 2: Transverse PET-CT

Figure 2

Figure 3: Cardiac CT

Figure 3

Figure 4: Cardiac MRI

Figure 4

The patient was then transferred from the smaller satellite hospital where he had initially presented to our urban teaching hospital for further evaluation and management. On arrival to the cardiac intensive care unit, he was noted to be complaining of marked exertional dyspnea and orthopnea. Physical examination was remarkable for significant jugular venous distention associated with bilateral pitting edema of the lower extremities. In the subsequent hours, the patient's condition continued to deteriorate, leading to the development of hypoxic respiratory failure with hemodynamic instability, requiring intubation and vasopressor support. Transthoracic echocardiography (TTE) was performed with poor visualization of a large mass within the right atrium (Figure 5). Image quality was impaired by patient positioning and mechanical ventilation. Thus, transesophageal echocardiography (TEE) was pursued, which noted a 4-cm-wide, heterogeneous, irregular, echogenic mass infiltrating the right atrial lateral free wall and protruding into the right atrium. The mass had multiple mobile, finger-like projections floating in the atrial cavity (Figures 6-7). Right ventricular systolic function was borderline reduced, and left ventricular function was preserved. The venae cavae and tricuspid valves were spared without obstruction.

Figure 5: TEE

Figure 5

Figure 6: TEE

Figure 6

Figure 7: TEE Three-Dimensional Reconstruction

Figure 7

What is the best next step to confirm a diagnosis?

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