ST Segment Elevation in a Patient with Cancer

A 64-year-old woman with past medical history of relapsed Hodgkin's lymphoma and asthma presented to the hospital for progressive difficulty walking, back pain associated with productive cough, and chills. She has been receiving radiation therapy for metastases in her spine but has been having increasing back pain. She had an episode of bowel incontinence and so was admitted for concern for cord compression. She was found to have fever, hypotension, lactic acidosis, and mild hyponatremia along with pancytopenia. She was started on aztreonam and vancomycin for febrile neutropenia.

Patient's vitals at presentation were blood pressure of 84/48 mmHg, pulse of 109 to 130 beats per minute, temperature of 39.1 degrees celsius and oxygen saturation of 90% on room air. Sodium was 131 mMol/L (136-145 mMol/L), BUN 42 mg/dL (7-25 mg/dL), Creatinine 1.03 mg/dL (0.6 to 1.2 mg/dL). Initial troponin I was normal at <0.04 ng/mL, WBC was 0.3 K/cumm (3.5 to 10.6 K/cumm), hemoglobin of 6.7 gm/dL (11.5 to 15.1 gm/dL) with platelets of 12 K/cumm (150-450 K/cumm). Blood cultures grew Escherichia coli and Klebsiella pneumonia. Magnetic resonance imaging (MRI) of lumbar spine showed possible epidural collection.

Patient had tachycardia for which she had an electrocardiogram (ECG) done (Figure 1) and cardiology was consulted stat due to acute findings compared to her baseline ECG (Figure 2). Examination revealed normal heart sounds and no additional sounds such as murmurs, rubs or gallops. An echocardiogram was performed which showed normal left ventricular size and thickness, mildly reduced left ventricular systolic function with ejection fraction of 45-50%, and no regional wall motion abnormalities, normal right ventricular size and function, and trivial posterior pericardial effusion.

Given her severe thrombocytopenia, lack of initial chest pain, and no wall motion abnormalities on echocardiogram, she was managed conservatively. She later started to have mild chest pain on deep breathing. Follow up ECG's over the course of the day (Figure 3 and Figure 4) are shown below. Troponins trended up to 2.70 ng/mL (Normal <0.04 ng/mL) within 24 hours and down to 0.32 ng/mL within the next 24 hours. D-dimer was elevated to 3.34 mg/L FEU (Normal high <0.50 mg/L FEU). BNP increased from 167 pg/mL (<101 pg/mL) at admission to 2443 pg/mL in 24 hours.

Figure 1: Initial ECG

Figure 1

Figure 2: Baseline ECG

Figure 2

Figure 3: ECG at 6 hours

Figure 3

Figure 4: ECG at 18 hours

Figure 4

What is the likely diagnosis?

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