Pericardial mesothelioma presenting as systemic lupus erythematosus

Pericardial mesothelioma mimicking mediastinal lymphoma and systemic rheumatic disease: a case report

Introduction

Pericardial mesothelioma is an exceedingly rare pericardial neoplasm. It has atypical clinical symptoms and imaging characteristics that often lead to an inconclusive diagnosis. The diagnosis of a rare tumor such as pericardial mesothelioma, which can present with a variety of manifestations, requires a multidisciplinary approach.

Case presentation

A 36-year-old Caucasian female patient without significant past medical history was admitted to the hospital with chest pain and a high fever and was diagnosed with acute pericarditis. The following month, the patient was treated for sepsis; during this hospitalization, lab tests for antinuclear antibodies (ANA) turned out to be positive. Concurrently, mediastinal lymphadenopathy was observed. Given the suspicion of mediastinal lymphoma, a mediastinoscopy with lymph node biopsy was performed. Following a negative biopsy result, positron emission tomography combined with computed tomography (PET/CT) and blood immunophenotyping were performed. Both tests ruled out a diagnosis of lymphoma. Concurrently, the patient was hospitalized in the rheumatology department due to positive ANA results. There, in addition to the ANA titer at a level of 1:320, lupus anticoagulant was detected. The patient was diagnosed with systemic lupus erythematosus (SLE) and initiated on chronic steroid therapy. As heart failure progressed, the patient was admitted to the cardiology department. Tissue Doppler echocardiography and cardiac magnetic resonance imaging (MRI) revealed features indicative of constrictive pericarditis. The patient underwent a pericardiectomy with satisfactory results. However, the pathology result of the pericardium remained equivocal. The patient was readmitted 3 months later with severe circulatory failure, and a salvage procedure of pericardiectomy was performed. Histopathological examination of the sections confirmed the diagnosis of pericardial epithelioid mesothelioma. The patient died after 3 weeks of palliative care.

Conclusions

In the differential diagnosis of relapsing and resultant constrictive pericarditis, neoplastic processes that may mimic systemic rheumatic diseases should also be considered. Pericardial mesothelioma is a very rare diagnosis and may result in increased ANA titers, particularly anti-dense fine speckled 70 (DFS70) antibodies.

A Case Report of Pericardial Effusion with False-Positive Mesothelioma and Adenocarcinoma Markers as the Initial Presentation of Systemic Lupus Erythematous

Pericardial effusion or the accumulation of fluid in the pericardial sac, can result from infectious, malignant, or autoimmune processes such as systemic lupus erythematous (SLE). However, pericardial effusion is infrequently the first presentation of SLE. Here, we describe the case of a 54-year-old African American woman who presented with hypertensive emergency and was found to have pericardial effusion on echocardiogram. Her hypertensive symptoms resolved with medical management and a work up were positive for serum markers of SLE and mesothelioma cell markers (calretinin, CK 5/6) and adenocarcinoma marker MOC31 in the pericardial fluid. Her effusion ultimately improved on high-dose steroid therapy and has not recurred in one year. Given normal pleura and pericardium on computed tomography (CT) imaging and long-term clinical improvement in SLE therapy, we hypothesize that she had false-positive mesothelioma markers in the setting of SLE.

A 75 year old male with recurrent unilateral pleural effusion and positive ANA

This case report describes the clinical course and diagnostic challenges arising in a 75 year old man who initially presented with progressive shortness of breath. Imaging revealed a pleural effusion, which was recurrent following thoracentesis. While his initial workup suggested an autoimmune etiology, further diagnostic testing revealed a diagnosis of malignant pleural mesothelioma. Curiously, the patient had no known asbestos exposure, which is classically associated with acquired mesothelioma. There are a small number of similar cases with a possible overlap between positive autoimmune serologies and mesothelioma; however, the underlying pathophysiology remains elusive. It is the authors' goal to contribute this case to the few cases describing such overlap syndromes.

A Rare Case of Malignant Mesothelioma Presenting with Systemic Lupus Erythematosus Seropositivity: A Case Report and Review of Literature

While malignant mesothelioma may initially present in a variety of ways, it is uncommon to present with systemic lupus erythematosus (SLE) seropositivity and thus obscuring its diagnosis. Our case involves a 75-year-old Caucasian male with a past medical history of essential hypertension, remote prostate cancer status post prostatectomy, and lifetime nontobacco use presenting with progressive shortness of breath over one month. After a negative cardiac assessment, a postcardiac catheterization chest X-ray (CXR) revealed a right-sided moderate-to-large pleural effusion that, on further workup, was found to be exudative. Effusion studies were negative for malignancy and bacterial growth. Recurrent accumulation of fluid after a thoracentesis one week prior prompted an autoimmune work up. Positive markers included antinuclear antibodies, anti-double stranded DNA antibodies, and anti-histone antibodies, while anti-Smith antibodies were negative. Although SLE was initially suspected based on serologies, no clinical signs or symptoms were present to fulfill the diagnosis criteria. A trial of oral prednisone resulted in decreased pleural effusion size with no further recurrence. Additional studies included a CT scan of the chest that showed pleural masses confirmed with biopsy to be epithelioid mesothelioma. Given the patient's age and new diagnosis of malignant mesothelioma, we hypothesized that the presence of autoantibodies was likely false positives due to acquired autoantibodies with age, hyperactivity of the immune system from malignancy, and possible prior asbestos exposure.

Epidemiology of mesothelioma of the pericardium and tunica vaginalis testis

PURPOSE

Malignant mesothelioma most commonly arises in the pleura and peritoneum but also occurs rarely at other anatomical sites with mesothelial tissue, namely, the pericardium and tunica vaginalis testis (TVT). This review provides a better understanding of the epidemiology of mesothelioma of these extrapleural sites.

METHODS

We conducted a systematic review of the epidemiologic and clinical literature on pericardial mesothelioma and mesothelioma of the TVT. We also analyzed U.S. Surveillance, Epidemiology, and End Results cancer registry data to describe incidence patterns of these malignancies.

RESULTS

An etiologic role of asbestos exposure has been hypothesized for pericardial and TVT mesotheliomas, but no analytical case-control epidemiologic studies exist to test this relationship. A substantial proportion of cases with these malignancies report no known asbestos exposure. In large occupational cohorts with heavy asbestos exposures, no cases of pericardial or TVT mesothelioma have been reported. Trends in the incidence of these malignancies do not match those of pleural mesothelioma, which correspond to historical trends of commercial asbestos use. A male preponderance of pericardial mesothelioma is not evident.

CONCLUSIONS

In the absence of analytic epidemiologic studies, the etiologic role of environmental risk factors for mesothelioma of the pericardium and TVT remains elusive.

A second case of pericardial mesothelioma mimicking systemic lupus erythematosus in the literature in over 30 years: a case report

Background

Mesothelioma is a rare neoplasm which commonly develops in the pleura of people exposed to asbestos. Pericardial mesothelioma accounts for only 0.7 % of all malignant mesotheliomas and it usually presents with pericardial effusion, mimicking serositis. To date, there are approximately 200 cases of pericardial mesothelioma described in the medical literature, and little knowledge exists about the systemic manifestations of this pathology. The first and only described case of pericardial mesothelioma with autoimmune features dates back to 1984 and, in our case report, we describe the second.

Case presentation

We report a case of a 45-year-old white woman whose pericardial mesothelioma was initially misdiagnosed as pericardial involvement of an autoimmune disease (systemic lupus erythematosus). After several relapses of pericardial effusion, a computed tomography scan and a biopsy with histological analysis were performed revealing neoplastic growth.

Conclusions

We describe a rare case of pericardial mesothelioma in a patient with a clinical presentation compatible with lupus serositis. Clinicians should consider malignant mesothelioma in the differential diagnosis of pericardial effusion, especially when it is recurrent and not clearly explained by other causes. Cytological samples should always be obtained and, if imaging tools are suggestive for solid processes, histological confirmation is mandatory.

Anti-cardiolipin antibodies, Raynaud's phenomenon with digital ischemia, and non small cell carcinoma of the lung

Raynaud's phenomenon, digital ischemia, antinuclear antibodies and anticardiolipin antibodies are uncommon features of malignancy. The association of all of these in a patient with malignancy has not previously been reported. We describe a 52 year old woman with non small-cell carcinoma of the lung who also had Raynaud's phenomenon, digital ischemia, anti-nuclear antibodies and anticardiolipin antibodies.

Primary malignant mesothelioma of the pericardium. Case report and literature review

Pericardial mesothelioma is a highly lethal and fortunately rare cardiac neoplasm. We present the clinical and pathologic features of a primary sarcomatoid mesothelioma. To better understand the clinical, radiographic, and pathologic features of this entity, we reviewed 27 cases described in the English literature from 1972 through 1992, which, together with our case, provided a total of 28 cases. Findings of the review include a male-female ratio of 2:1, a wide age range (12 to 77 years; mean, 47 years), and documented asbestos exposure in 4 of 28 (14%) patients. Commonly used imaging studies do not appear to offer great sensitivity, for a mass was detected by echocardiography in only 2 of 16 (12%) patients and by computed tomography in 4 of 9 (44%). Pathologic findings revealed a diffuse growth pattern in most cases (18 of 25, or 72%), together with an equal distribution between the biphasic, epithelioid, and sarcomatoid variants. Effusion cytology revealed malignant cells in only 2 of 10 (20%) cases. With or without therapy, prognosis was uniformly poor, since 24 of 27 patients were dead of the disease at the time the reports were published.

Background incidence of mesothelioma: animal and human evidence

Evidence is presented showing that mesotheliomas can have causes other than exposure to asbestos dust, in both experimental animals and humans. In experimental animals, for example, results from two major experimental laboratories suggest that at least 10% may be taken for background incidence, whereas a third laboratory suggests that the experimental group must have a rate exceeding 30% "Background" also includes mesotheliomas found in association with nonfibrous and fibrous nonasbestiform agents. Mesotheliomas in humans can be broadly classified in a manner similar to those of experimental animals: (1) spontaneously occurring, (2) those with a latent period less than 10 years, (3) childhood mesotheliomas, (4) familial cases, (5) cases before the 20th century, (6) mineralogically negative mesotheliomas, and (7) mesotheliomas caused by nonasbestiform agents. The importance of the acceptance of these "background" cases lies in the fact that a basis is provided for the study of the incidence of disease associated with various types of asbestos.