THE GREAT MASQUERADER OF RHEUMATOLOGICAL SYMPTOMS: A CASE REPORT

BackgroundPrimary cardiac tumors are extremely rare,and out of those atrial myxoma is the most common benign tumor (75%).Around 75% of the atrial myxoma cases arise from left side of the heart and present differently from right sided. Due to its varied presentation in regard to constitutional,embolic and obstructive features it mimics vasculitis.ObjectivesTo create awareness about the atrial myxoma, the great mimicker of vasculitis and comment upon its clinical course and complications if not treated timely.MethodsCase report and Discussion.Results34 year old female with no past medical history came to the Rheumatology Department after failure to be diagnosed. She had 8 months history of pain in her finger tips, toes, small joints and Raynauds phenomenon. Intermittent fever associated with chills, palpitations, sweating and significant weight loss was noted during the course of illness. Before visiting our clinic, she was treated for Typhoid fever but she didn’t respond. At presentation, her vitals and physical examination including auscultation was unrevealing.Her blood counts showed Hb at 8g/dL, metabolic panel,LFTs,coagulation profile were normal.But had high ESR levels in multiple reports ranging from 60-168mm/hour. CRP was also positive. Hypocomplementmia and increase in alpha-globulins were observed.ANA positive,dsDNA negative APLA, P and C-ANCA and Cryoglobulins were also negative.PET-CT was negative for avid FDG uptake in any organ. Patient was given iron formulations intravenously and was advised to cardiology in view of significant palpitations which was not given much attention before.Echo showed 4.1x 3.3cm, pedunculated mass arising from inter-atrial septum and anterior mitral leaflet (Figure 1).Patient was started on ecosprin and advised surgery which got postponed due to patient having complications of acute limb ischemia and stroke in right fronto-parietal lobe (Figure 1.) subsequently. She had multiple embolectomies of right brachial and bilateral femoral arteries, later followed by craniectomy and decompression from the hemorrhage with subsequent cranioplasty and at lastly removal of mass. The surgical pathological report of mass showed features characteristic of myxoma which concluded the diagnosis.After surgeries,the patient is doing much better.Her Hb levels have improved to 12g/dL and the ESR level came back to normal.Though there is residual weakness due to stroke but she has shown significant recovery in terms of modified Rankin scale of 3.No more systemic complaints like fever, fatigue, Raynauds phenomenon and digital pain are observed.In this case, duration from onset of symptoms to hospitalization for life threatening was complete one year with added 6 months to significant recovery from complications.ConclusionMyxoma, a rare intracardiac benign neoplasm due to release of inflammatory cytokines like IL-6 and embolic mechanism can present as inflammatory rheumatic disease. Diagnosing this great masquerader can be challenging even for a specialist but timely ordering of certain non-invasive tests could be life saving for the patient. For example in this case, Echocardiography or Cardiac MRI are critical. Therefore, having high diagnostic suspicion is very important when dealing with vasculitis and its mimics.References[1]Reynen K. Cardiac myxomas. N Engl J Med. 1995;333(24):1610-17 [2]Sack KE. When vasculitis is not vasculitis. Hosp Pract (Off Ed). 1993 Jul 15;28(7):94, 97-100, 103. doi: 10.1080/21548331.1993.11442825. PMID: 8325920.AcknowledgementsBIRAC (Biotechnology Industry Research Assistance Council).Disclosure of InterestsNone Declared.