Cardiac Case: 42-year-old Woman with Joint Discomfort, Low Grade Fever, and Dyspnea

by Joseph Alpert, MD

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    00:01 A previously healthy 42-year-old woman comes in complaining of several weeks of diffused joint discomfort, low-grade fever, and shortness of breath -- dyspnea.

    00:10 She reports that recently she fainted while standing up in her bedroom and she also noted that one cold morning recently her fingertips turned white and became painful and this resolved when she placed her hands under warm water.

    00:23 She has no personal history of rheumatic fever as a child.

    00:27 On physical exam, she appeared to be ill and uncomfortable, blood pressure was not remarkable at 110/73 mmHg, heart rate not remarkable at 79/min but she did have a short presystolic low-pitched murmur heard over the apex with the patient lying on her left side.

    00:44 A little bit like this: so here's normal, lub-dub, lub-dub, and you hear her right here over the apex, lying on the left side you hear, lub-dubuuuu, lub-dubuuuu, lub-dubuuuu.

    00:57 So, there's a diastolic murmur there, presystolic.

    01:00 What's going on there? Well, we'll see in a moment.

    01:04 She has a chest X-ray that's unremarkable, an ECG that's unremarkable. So, what's going on in this? First of all, she has some non-specific symptoms of some sort of inflammatory process that's possibly involving the lung and the heart, not very specific.

    01:23 Then she has a syncope episode which is of great concern and she had Raynaud syndrome there where her fingertips turn white in the cold.

    01:32 She has a diastolic murmur so this is suggestive that something's going on, is there problem of the valve? And then we do an Echo and the Echo shows a myxoma in the left atrium.

    01:45 And the myxoma in the left atrium could get - can sort of partially plug the mitrial valve and imitate mitral stenosis and that's why we hear the little diastolic rumbling murmur that sort of imitates mitral stenosis.

    01:57 So, this myxoma, it has actually a risk that its pieces will break off, go to the brain and elsewhere, can cause stroke or limb ischemia so consequently, what do we have to do? We have to get that thing out of there.

    02:13 Often, myxoma is associated with systemic symptoms presumably because of substances coming off of the tumor itself.

    02:21 Patients can have arthralgias, joint discomfort, low-grade fevers, dyspnea, and even occasional syncope when the ball of the myxoma actually gets stuck transiently in the mitral valve.

    02:35 And as I said before, it can mimic mitral stenosis. The treatment of course is surgical removal.

    02:41 The tumor is almost always benign but it can recur if the excision is not complete.

    02:47 And this lady had her tumor resected.

    02:50 She did very well long-term and had no more problems.

    About the Lecture

    The lecture Cardiac Case: 42-year-old Woman with Joint Discomfort, Low Grade Fever, and Dyspnea by Joseph Alpert, MD is from the course Cardiovascular Cases.

    Included Quiz Questions

    1. Echocardiogram
    2. Chest CT scan
    3. 24-hour Holter monitoring
    4. Erythrocyte sedimentation rate
    5. B-natriuretic peptide
    1. Transcatheter resection
    2. Open surgery
    3. Systemic chemotherapy
    4. Local radiation
    5. Medical therapy

    Author of lecture Cardiac Case: 42-year-old Woman with Joint Discomfort, Low Grade Fever, and Dyspnea

     Joseph Alpert, MD

    Joseph Alpert, MD

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