Fibrous Pericardial Mass Signifying the Importance of Advanced Cardiovascular Imaging: A Case Report

Background

Pericardial masses are an extremely rare group of diseases which can be classified based on etiology. The presentation of pericardial masses varies considerably from one individual to another, ranging from an asymptomatic presentation with an incidental finding on imaging, to presenting with non-specific signs and symptoms. Due to the enigmatic nature and presentation of pericardial masses, diagnostic imaging is mandatory.

Case Presentation

A 69-year-old patient presented to our cardiology clinic complaining of intermittent shortness of breath upon moderate exertion in the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, dizziness, palpitations, or lower limb edema. The patient's past medical history was significant because of his history of pericarditis associated with pericardial effusion 6 years prior to presentation at our clinic. Despite adequate medical treatment, the patient complained of a relapsing and remitting pattern of symptoms that mandated the performance of advanced cardiovascular imaging, namely, cardiac magnetic resonance imaging, which revealed the presence of a profound pericardial mass.

Conclusion

Despite the fact that relapsing pericarditis is a well-established complication following acute pericarditis, the presentation of a complication such as a fibrous pericardial mass evident on cardiac MRI has essentially been unreported in the literature previously.

A Case of Pericarditis and Pericardial Masses Associated With Mycobacterium Paragordonae

Tuberculosis is a common cause of pericarditis worldwide and has been associated with pericardial masses. Non-tuberculous mycobacteria are uncommonly associated with cardiac disease, having primarily been described in cases of endocarditis. Here we describe a case of an immunocompetent patient with Mycobacterium paragordonae infection causing pericarditis with a large effusion containing pericardial masses. The patient presented with chest pain, hypoxia and biochemical evidence of inflammation (CRP 216.1 mg/L). This report illustrates a rare case of pericarditis with pericardial masses associated with non-tuberculous mycobacteria and the first example of pericarditis associated with M. paragordonae.

Cardiac Amyloidosis in the Setting of a Sarcomatous Pericardial Mass

Cardiac amyloidosis is a significantly underdiagnosed disease but should be suspected in anyone with restrictive heart physiology. Here, we present a case of a sarcomatous pericardial mass confounding the patient's progressive diastolic heart failure. Amyloidosis was eventually discovered by piecing together serial transthoracic echocardiogram, functional MRI, and technetium-99m (99mTc) pyrophosphate scintigraphy findings along with a negative lab workup. The presence of the sarcomatous pericardial mass raised the question of whether it played a role in the onset and progression of amyloidosis, but nonetheless, the presence of both diseases rendered multifaceted challenges regarding our patient's care. Anyone suspected to have amyloidosis should receive appropriate testing for a definitive diagnosis to catch the disease process and offer early treatment, as exciting research is emerging showing transthyretin stabilizers to have a reduction in all-cause mortality.

A case of metastatic primary cardiac angiosarcoma

We report a 49-year-old Southeast Asian woman diagnosed with metastatic primary right atrial angiosarcoma (PCA) and the difficulties encountered in this diagnosis and its subsequent management. Diagnosis of PCA is often delayed due to non-specific clinical presentation of patients. These tumours often present once metastatic spread has occurred, restricting treatment options and leading to very poor prognosis. Patients undergo a multidisciplinary team (MDT) approach involving chemotherapy, radiotherapy and, if eligible, surgery, but evidence-based treatment guidelines have yet to be established due to the rarity of the tumour.

Role of cardiovascular magnetic resonance in an adolescent with a giant intrapericardial mass

A 14 -year-old boy presented with chest pain and breathlessness. Echocardiography showed a large pericardial effusion with cardiac tamponade features and suspicion of cardiac mass. Cardiovascular magnetic resonance demonstrated a large, well-defined pericardial mass, suggesting atypical large coronary fistula with pericardial haematoma or primary cardiac/pericardial tumour such as angiosarcoma. Histology confirmed a mixed-type vascular malformation. Sirolimus therapy was initiated.

A lymphoproliferative pericardial mass

Castleman disease (CD) is a rare lymphoproliferative disorder with variable presentation and prognosis. Most CD cases are unicentric and correspond to the hyaline-vascular variant, a histopathological classification associated with better outcomes, which commonly presents as an enhancing hypervascular mediastinal mass. CD is often asymptomatic and surgically resectable. Nonetheless, surgical resection can be difficult when the lymphoid mass is causing compression of vital structures. We discuss a rare case of hyaline-vascular unicentric CD presenting as an incidental pericardial mass.

Sarcoidosis Presenting as a Right Paraesophageal Mass Abutting the Left Atrium

We herein report a unique case of sarcoidosis in a 44-year-old Caucasian female. The patient was initially evaluated for hematochezia and diagnosed with diverticulitis after computed tomography (CT) scan of the abdomen and pelvis. This imaging also incidentally showed a large mass abutting the esophagus. Further imaging of the mass revealed widespread lymphadenopathy in the thorax without any respiratory or classic B symptoms present. The remaining workup caused concern for possible lung or hematologic malignancy. Following biopsy of a thoracic lymph node, the patient was diagnosed with sarcoidosis. This patient met only one of the usual demographic criteria associated with sarcoidosis and none of the lab criteria. While sarcoidosis is typically a benign disease, this case exemplifies how it may appear as a more sinister entity and warrants extensive workup to rule out malignancy.

Lesson of the month 1: Pericardial mass and cardiac tamponade associated with Mycoplasma pneumoniae

Mycoplasma pneumoniae primarily causes respiratory tract infections. Extrapulmonary manifestations are seen in 20-25% of cases. Cardiac involvement is rarely reported. We present a unique case of a pericardial mass and cardiac tamponade associated with a Mycoplasma pneumoniae pneumonia. This required emergency pericardial fenestration. The patient improved dramatically postoperatively on antibiotics and there was no recurrence of the pericardial effusion on follow up. This case highlights the often forgotten invasive properties of a common respiratory tract pathogen and emphasises the need to consider this easily treatable entity in the differential diagnosis of idiopathic pericardial effusions.