An Uncommon Mimic of Acute Coronary Syndrome: Infiltrating Non-Hodgkins Lymphoma

Published:February 03, 2018DOI:
      A 73-year-old man presented with a 4-hour history of substernal chest pain, dyspnea, nausea, and emesis. His past medical history included diabetes mellitus type II, coronary artery disease with single-vessel coronary artery bypass grafting, hyperlipidemia, chronic kidney disease stage 3 due to membranoproliferative glomerulonephritis, and a 25-pound unintentional weight loss over the past 3 months. On presentation, he was hypotensive, with blood pressure 90/68 mm Hg. Physical examination showed bibasilar crackles,prominent pulmonic heart sound, and bilateral lower-extremity pitting edema. Labs revealed troponin T elevation (O hour: 0.73 ng/mL, 3 hours: 0.61 ng/mL, 6 hours: 0.58 ng/mL) and electrocardiogram demonstrated 0.1 mV ST elevation in leads II, III, and AVF, as well as new T-wave inversions across the precordium. He underwent urgent coronary and vein graft angiography, which revealed widely patent coronary arteries, a chronically occluded single vein graft, and an akinetic and enlarged right ventricle. Urgent echocardiogram demonstrated an extensive extracardiac mass encasing the right ventricle and severe right ventricular dysfunction (Figure 1).
      Figure 1
      Figure 1Transthoracic echocardiogram. Large inhomogeneous mass in the epicardial space. The right ventricle has a thickened wall, essentially at standstill. There is severe right ventricular dysfunction.
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