Adam Sturts, DO
Resident Physician
Penn State Health Milton S. Hershey Medical Center
Hershey, Pennsylvania
Disclosure information not submitted.
Nikhita Kothari, DO
Cardiology Fellow
Rowan University School of Osteopathic Medicine, United States
Disclosure information not submitted.
Adrian Pearson, DO
Cardiologist
Tower Health Medical Group, United States
Disclosure information not submitted.
Title: A Case of Primary Cardiac Lymphoma Presenting As Electrical Storm
Case Report Body:
Introduction: Primary cardiac lymphoma (PCL) is a rare, life-threatening malignant neoplasm involving the heart and/or pericardium. Clinical presentation varies depending on tumor location, burden and extent of invasion. It most commonly involves right heart chambers. Ventricular arrhythmia is a potentially fatal complication.
Description: A 55-year-old male with obesity, obstructive sleep apnea and hypertension presented to an outside emergency department after a witnessed syncopal episode. En route, he had ventricular fibrillation induced cardiac arrest and received 1 external shock with successful conversion to sinus rhythm. Initial ECG showed sinus rhythm with incomplete right bundle branch block. Due to frequent runs of monomorphic ventricular tachycardia (VT) and concern for myocardial ischemia, he was started on intravenous amiodarone infusion, medical therapy and was transferred to a cardiac center.
He underwent left heart catheterization that showed no obstructive coronary artery disease. He continued to have runs of VT so was transitioned to sotalol infusion without improvement. Bedside echocardiogram revealed severely increased right ventricle wall thickness extending to the right atrium, ejection fraction 60% and a large circumferential pericardial effusion with fibrinous characteristics. He underwent urgent pericardiocentesis. Due to persistent episodes of VT despite amiodarone, sotalol infusion, he was started on intravenous lidocaine and maintained in sinus rhythm.
CT and CMR showed a large infiltrative mass involving the base of the right and left ventricles with areas of necrosis and delayed gadolinium enhancement; characteristics consistent with cardiac lymphoma. Subsequent video assisted thoracoscopic surgery, pericardial window and biopsy revealed diffuse large B cell lymphoma. He was started on prednisone and monitored for arrhythmia during his first session of R-EPOCH therapy with no further VT. He received a single chamber implantable cardioverter-defibrillator before discharge without recurrence of his VT.
Discussion: Electrical storm is a rare and potentially lethal complication of PCL. PCL induced ventricular arrhythmia may be refractory to first line therapy. In this case, it was responsive to lidocaine infusion with no recurrence of VT following R-EPOCH treatment.