Right atrial myxoma: a potential accelerator of pulmonary hypertension in the course of systemic sclerosis. The role of interleukin-6

Giant right atrial myxoma presented with symptoms of Budd-Chiari syndrome: a case report

Introduction and importance

Right atrial myxoma is rarely associated with Budd-Chiari syndrome (BCS). In this paper, we present a case of a young patient with a giant right atrial myxoma complicated by the development of BCS.

Case presentation

A 26-year-old female presented to the emergency room with persistent abdominal pain, ascites, lower limb edema, and an acute episode of dyspnea. Abdominal computed tomography revealed a lesion in the right cardiac cavity that resembled an intracardiac thrombus. Transthoracic echocardiography showed a large heterogeneous mass in the right atrium protruding into the right ventricle and a large thrombus interfering with inferior vena cava flow. The patient underwent cardiac surgery to remove the atrial mass, and histopathologic examinations confirmed the diagnosis of atrial myxoma.

Clinical discussion

The right atrial myxoma is relatively rare, especially the giant ones. Rarely have intracardiac tumors such as giant right atrial myxoma been identified as a risk factor for the onset of BCS.

Conclusion

In the differential diagnosis of BCS, right atrial tumors, including myxomas, should be considered, especially when other explanations are absent.

Cytokine Drizzle-The Rationale for Abandoning "Cytokine Storm"

BACKGROUND

"Cytokine storm" has been used to implicate increased cytokine levels in the pathogenesis of serious clinical conditions. Similarities with Severe Acute Respiratory Syndrome Coronoavirus-2 (SARS CoV-2) and the 2012 Middle Eastern Respiratory Syndrome led early investigators to suspect a "cytokine storm" resulting in an unregulated inflammatory response associated with the significant morbidity and mortality induced by SARS CoV-2. The threshold of blood cytokines necessary to qualify as a "cytokine storm" has yet to be defined.

METHODS

A literature review was conducted to identify cytokine levels released during 11 assorted clinical conditions or diseases. Weighted averages for various cytokines were calculated by multiplying the number of patients in the paper by the average concentration of each cytokine. Correlation between cytokine levels for individual conditions or diseases were assessed using Pearson correlation coefficient.

RESULTS

The literature was reviewed to determine blood levels of cytokines in a wide variety of clinical conditions. These conditions ranged from exercise and autoimmune disease to septic shock and therapy with chimeric antigen receptor T cells. The most frequently measured cytokine was IL-6 which ranged from 24,123 pg/mL in septic shock to 11 pg/mL after exercise. In patients with severe SARS CoV-2 infections, blood levels of IL-6 were only 43 pg/mL, nearly three magnitudes lower than IL-6 levels in patients with septic shock. The clinical presentations of these different diseases do not correlate with blood levels of cytokines. Additionally, there is poor correlation between the concentrations of different cytokines among the different diseases. Specifically, blood levels of IL-6 did not correlate with levels of IL-8, IL-10, or TNF. Septic shock had the highest concentrations of cytokines, yet multiple cytokine inhibitors have failed to demonstrate improved outcomes in multiple clinical trials. Patients with autoimmune diseases have very low blood levels of cytokines (rheumatoid arthritis, IL-6 = 34 pg/mL; Crohn's disease, IL-6 = 5 pg/mL), yet respond dramatically to cytokine inhibitors.

CONCLUSION

The misleading term "cytokine storm" implies increased blood levels of cytokines are responsible for a grave clinical condition. Not all inflammatory conditions resulting in worsened disease states are correlated with significantly elevated cytokine levels, despite an association with the term "cytokine storm". "Cytokine storm" should be removed from the medical lexicon since it does not reflect the mediators driving the disease nor does it predict which diseases will respond to cytokine inhibitors.