A 44-year-old man comes to the office due to transient vision loss in his right eye. He has experienced fatigue, warmth, and unintentional weight loss over the last 2 months. HIV testing 4 weeks ago was negative. Family history is unremarkable.
The patient's blood pressure is 122/70 mm Hg and pulse is 78/min. A faint diastolic murmur is heard at the apex.
ECG shows T-wave inversion in the lateral leads. Two sets of blood cultures are negative.
Which of the following is the most likely diagnosis in this patient?

Question

A 44-year-old man comes to the office due to transient vision loss in his right eye.  He has experienced fatigue, warmth, and unintentional weight loss over the last 2 months.  HIV testing 4 weeks ago was negative.  Family history is unremarkable.
The patient's blood pressure is 122/70 mm Hg and pulse is 78/min.  A faint diastolic murmur is heard at the apex.
ECG shows T-wave inversion in the lateral leads.  Two sets of blood cultures are negative.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_976a_5b9a_853d_6da2f059ca40_MD0002_00 This patient's presentation with transient vision loss (amaurosis fugax), unintentional weight loss, and diastolic murmur is suggestive of cardiac myxoma. Myxomas are the most common benign primary cardiac tumors, with approximately 80% located in the left atrium. Left atrial myxomas can cause obstruction of blood flow across the mitral valve, mimicking mitral valve disease and producing an early diastolic sound ("tumor plop"). Patients often have fatigue, cough, dyspnea, orthopnea, pulmonary edema, or hemoptysis. Left atrial tumors can also cause systemic embolization (eg, transient ischemic attack, stroke, splenic infarcts). About 50% of patients have constitutional symptoms (due to overproduction of interleukin-6) such as fever, weight loss, or Raynaud phenomenon. Although transesophageal echocardiography (TEE) is the most sensitive test for diagnosis, transthoracic echocardiography is usually adequate. Once the diagnosis is established, prompt surgical resection is recommended to avoid complications of embolization and risk of sudden death. transesophageal echocardiography (Choice A) Ascending aortic aneurysms are usually asymptomatic and may present initially as aortic dissection or rupture with sudden onset of tearing chest/back pain, hemodynamic collapse, and death. Large aneurysms can also cause compression of adjacent structures and present with dysphagia (esophageal compression), hoarseness (compression of recurrent laryngeal nerve), or hemidiaphragmatic paralysis (phrenic nerve compression). Aneurysms involving the aortic root can present with congestive heart failure due to chronic aortic regurgitation. (Choice B) Carcinoid heart disease is a complication of carcinoid syndrome that most commonly affects the right side of the heart. Patients typically present with fatigue, dyspnea on exertion, cachexia, and signs of right-sided heart failure. Symptoms of carcinoid syndrome, such as flushing, secretory diarrhea, bronchospasm, and hypotension, may be present. (Choice D) Factor V Leiden homozygosity (80-fold) or heterozygosity (7-fold) is associated with increased risk for venous thrombosis (eg, deep-vein thrombosis with pulmonary embolism; cerebral, mesenteric, and portal vein thrombosis). It is usually not associated with arterial emboli, as seen in this patient. Constitutional symptoms are not typical. (Choice E) Hypertrophic cardiomyopathy most commonly involves asymmetric septal wall hypertrophy, with left ventricular outflow obstruction symptoms (eg, syncope, dyspnea, chest pain) and sudden cardiac death. It is not associated with embolic events. Educational objective: Myxomas are the most common benign primary cardiac tumors, with approximately 80% located in the left atrium. Patients typically develop constitutional symptoms (eg, fatigue, low-grade fever, weight loss), systemic embolization (eg, transient ischemic attacks, ischemic stroke, acute embolic arterial occlusion), and cardiovascular symptoms simulating mitral valve disease (eg, dyspnea, orthopnea, cough, pulmonary edema, hemoptysis). __________ References: Central nervous system manifestations of cardiac myxoma. (http://www.ncbi.nlm.nih.gov/pubmed/17698701) Clinical presentation of left atrial cardiac myxoma. a series of 112 consecutive cases. (http://www.ncbi.nlm.nih.gov/pubmed/11388092)

A 44-Year-Old Man Comes to the Office Due to Transient