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Prolonged fever and a murmur in a 35-year-old man
  1. Akihiro Tanaka,
  2. Masami Nishino,
  3. Yasuyuki Egami,
  4. Ryu Shutta,
  5. Jun Tanouchi
  1. Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
  1. Correspondence to Dr Masami Nishino, Division of Cardiology, Osaka Rosai Hospital, 1179-3, Nagasone-cho, Sakai-city, Osaka 591-8025, Japan; mnishino{at}orh.go.jp

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Clinical introduction

A 35-year-old man was referred to our hospital for dyspnoea and prolonged fever of unknown origin for a month. He had a high-pitched pan-systolic murmur at apex radiating to the clavicular area. His laboratory data showed elevated inflammatory indices (white-blood cells 14 800/μL and C-reactive protein 8.26 mg/dL). A chest radiograph revealed a moderate cardiomegaly (cardiothoracic ratio=0.60), and an ECG revealed atrial fibrillation. Transthoracic and transoesophageal echocardiography were performed (see figures 1 and 2, videos 1, 2 and 3). Two sets of blood cultures yielded Actionobacillus.

Figure 1

Transthoracic echocardiographic images. (A) Apical four-chamber view. (B) Apical two-chamber view.

Figure 2

Transesophageal echocardiographic images.

Clinical question

The most likely diagnosis in this patient is:

  1. Infective endocarditis

  2. Myxomatous mitral valve disease

  3. Papillary muscle rupture

  4. Atrial myxoma

  5. Rheumatic mitral valve disease

For the answer see page 1044

From the question on page 1112

Answer: D

A large mobile mass attached to the left atrium by a stem was considered as myxoma because of its location and form. Transthoracic echocardiography demonstrated severe mitral valve regurgitation due to prolapse of the A3 segment and P3 scallop in addition to myxoma. There was no evidence of vegetation, and the mass attacked the valve leaflets like a wrecking ball—an iron ball suspended from a crane and swung to demolish buildings (video 4). Harvey1 described the phenomenon as ‘the wrecking ball effect’.

The patient underwent surgery. Pathological findings were consistent with a typical myxoma, but also inflammation with infiltration of neutrophil and calcification (figure 3). Infected myoxma was extremely rare but it may cause unknown fever.2 ,3 He made an uneventful recovery.

Figure 3

(A) Inflammation with infiltration of neutrophil (arrow) was found in the cardiac mass. (B) Calcification part was found in the cardiac mass.

If myxoma and positive blood cultures coexist, we should suspect infected cardiac myxoma. Additionally, we should pay attention to severe mitral regurgitation by the wrecking-ball effect, especially when the myxoma is calcified.4

References

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Footnotes

  • Contributors All authors substantially contributed to the work and meet the authorship criteria as follows; conception and design, or analysis and interpretation of data: AT, YE, RS. Drafting the article or revising it critically for important intellectual content: MN. Final approval of the version to be published: MN, JT.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval The medical ethics committee at Osaka Rosai Hospital.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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