Abstract

Patient X, a forty-year-old woman, was initially admitted with a three-week history of flu like symptoms, fatigue, breathlessness and intermittent palpitations. In the emergency department, she had a run of supraventricular tachycardia which self resolved. Her blood tests showed a raised D-dimer and Troponin, severe iron deficiency anaemia and EBV DNA negative. Given her raised troponin and flu like symptoms, she was initially managed as acute myocarditis. During the admission she was started on low dose bisoprolol and placed on telemetry. This picked up several episodes of sinus pauses, therefore bisoprolol was held. The patient then went on to have further episodes of supraventricular tachycardia, once requiring chemical cardioversion with adenosine and the other with DCCV given haemodynamic instability, with further asymptomatic sinus pauses. Patient X had several investigations including a transthoracic echocardiogram, CTPA, cardiac MRI Scan and a CT abdomen and pelvis. The results overall demonstrated an abnormal thickening in the right atrial wall and interatrial septum with bilateral ovarian masses, right adrenal mass and abnormal retroperitoneal nodes. CT PET Scan was suggestive of lymphoma. Biopsies of the bone marrow and ovary confirmed diffuse large B-cell lymphoma. Given the tachy-brady arrhythmia and the diagnosis of lymphoma with cardiac involvement, an MDT took place to discuss the possible need of pacing. It was concluded to begin high dose steroids and monitor for any further arrhythmia. Patient X was started on R-CHOP chemotherapy and high dose methotrexate. She clinically improved with no further arrhythmias and was safely discharged home, she is currently in remission. Discussion:Cardiac lymphoma, particularly primary cardiac lymphoma, is rare. Whilst disseminated lymphoma, most often of non-hodgkin’s type, is well recognised, the myriad presentations and the often insidious onset regularly lead to delays in diagnosis and treatment. Treatment outcomes are often poor, with 30–40% of patients requiring second line treatment. This condition most commonly affects vulnerable patient populations including the elderly and the immunocompromised. This case report is unique amongst the literature due to young age at presentation, combined with her immunocompetent state and paucity of past medical history prior to this event. The presence of thickening in the right atrium and ventricle was in keeping with the known pattern of cardiac lymphomatous infiltration. However the combination of both brady- and tachyarrhythmias was very rarely described in the literature. As this patient remained wholly stable despite the arrhythmic episodes the decision was made not to implant a pacemaker and this has been of benefit to the patient in the long term. At 6 months the patient’s follow up PET-CT was lymphoma free following 6 cycles of R-CHOP chemotherapy, conveying the importance of early diagnosis and aggressive treatment in the short to medium term.Learning points:1) The myriad ways in which cardiac lymphoma can present confer low clinical suspicion and often delays in diagnosis and thereafter the necessary aggressive management strategy needed to treat the condition and its sequelae2) Pacemaker insertion should be based upon clinical need and can be avoided in scenarios where the patient remains stable and chemotherapy has been initiated to good effect.