|Year : 2015 | Volume
| Issue : 1 | Page : 27-29
Right Atrial Mass: An Accidental Echocardiographic Finding
Ibrahim Aliyu, Safiya Gambo
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
|Date of Web Publication||14-Mar-2015|
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Intracardiac tumors are rare and may be primary or of secondary metastasis; among primary tumors are atrial myxomas; these are most common in the left atrium, affect females more and it is seen more among teenagers in pediatric population. It has varied clinical presentation, and asymptomatic cases have been reported. However, the case of a 2-year-old female with the right atrial involvement who presented with overt signs severe malnutrition is reported.
Keywords: Myxoma, right atrium, severe malnutrition
|How to cite this article:|
Aliyu I, Gambo S. Right Atrial Mass: An Accidental Echocardiographic Finding. Heart India 2015;3:27-9
| Introduction|| |
Cardiac tumors are neoplasms arising from the inner linings of the heart, the muscle layer or the surrounding pericardium of the heart,  they may be primary or metastatic. Primary cardiac tumors are rare with a prevalence of 0.0017-0.28 in autopsy series. 
The majority of primary cardiac tumors in children are benign with only about 10% being malignant.  Rhabdomyomas are the most frequently reported benign tumors with 75% of cases found in children less than 1-year of age.  This is followed by fibroma, myxoma and teratoma.  Sarcoma is the largest group of primary malignant cardiac neoplasms with angiosarcoma being the most common histologic type.  Secondary metastatic tumors are 10-20 times more prevalent.  Cardiac myxomas are intracavitary masses. They are sporadic though a familial incidence has been described in up to 7% of cases. 
Early diagnosis of intracardiac tumors is important to prevent severe complication of embolization. We present the case of a 2-year-old girl with an incidental echocardiographic finding of right atrial myxoma who also had manifestations of malnutrition.
| Case report|| |
A 2-year-old girl presented with a history of recurrent breathlessness and body swelling for a month. Swellings initially involved the lower limbs and gradually progressed to involve the abdomen and face. No history suggestive of cyanosis. No genitourinary symptoms. There was a history of low-grade fever. She was weaned at the age of 20 months and was on the family diet that was well tolerated. Symptoms had progressively increased which necessitated referral from the peripheral hospital. She was delivered at term, and the delivery and neonatal period were not adversely eventful. There was no family history of similar problem. She had bilateral pitting pedal edema and was malnourished with a weight of 9.3 kg (z = <−3) and was stunted with a height of 82 cm (z = <−3) with mid-arm circumference of 11.5 cm [Figure 1], while the occipito-frontal circumference was 45 cm.
She had an oxygen saturation of 80% in room air, pulse rate of 126 beats/min, normal volume and regular peripheral pulses, the blood pressure was 90/60 mmHg, cardiac apex was located at 5 th left intercostal space lateral to the mid clavicular line, heart sounds were first, second and a third heart sound with pansystolic murmur (4/6) at the left lower sternal margin. She was tachypneic with a respiratory rate of 60 cycles/min. She had hepatosplenomegaly with moderate ascites. She was diagnosed to have severe malnutrition in heart failure.
Complete blood count showed neutrophilia of 85%, lymphocytes of 15%. Blood film revealed anisocytosis and polychromasia. Urea was 4.2 mmol/l, Na + 128 mm ol/l, K + 2.8 mmol/l, Cl 100 mmol/l, HCO 3 28 mmol/l, creatinine 92 mmol/l, which were normal except for the hyponatremia and hypokalemia. Urinalysis was normal. She received frusemide and antibiotics.
Chest X-ray findings revealed cardiomegaly [Figure 2]; electrocardiogram showed right axis deviation [Figure 3]; transthoracic echocardiographic study (SonoScape SSI-8000 series) using 7.5 MHz transducer revealed a well circumscribed spherical right atrial mass measuring 6 mm × 5 mm plunging the tricuspid valve during diastole with a thin stalk attached to the atrial septum; with associated tricuspid regurgitation [Figure 4] and [Video 1]. Based on these findings the diagnosis of right atrial myxoma was made.
| Discussion|| |
Myxomas are cardiac tumors with particular predilection to females.  The left atrium is the most common location, , but the index case had right atrial involvement. Amongst pediatric patients, teenagers are mostly affected. Presentation is often vague as they may not cause cardiac murmurs and presenting symptoms may not suggest a cardiac cause.  However delayed presentation may manifest with signs of cardiac decompensation.  Breathlessness, syncope, congestive heart failure, arrhythmia and constitutional symptoms are the most common forms of presentation as was observed in the index case.  In addition to these our patient was also malnourished, which was attributed to secondary malnutrition from the heart failure.
Ronald in his communication described the case of three children with left atrial myxomas who suffered major arterial occlusion with consequent permanent morbidity before the diagnosis established.  These case reports also emphasized that atrial myxomas are perhaps not as uncommon in children as was previously thought and that this diagnosis must be considered in any child that presents with systemic embolus.  Roudaut et al., reported a case of asymptomatic presentation in a 7-year-old boy whose diagnosis was made by M mode echocardiography following complaint of a cardiac murmur.  These cases further highlight the unpredictability of the clinical presentation of atrial myxoma, however there are few reports of atrial myxoma in Nigerian children,  and an intracardiac bronchogenic cyst;  the index case will, therefore, add to the body of knowledge on this subject.
The diagnostic tool in the initial evaluation of cardiac tumors is echocardiography providing excellent anatomical and functional information.  Magnetic resonance imaging is however the most sensitive and could serve as adjunct with echocardiography as the main diagnostic tool in the future. , On echocardiography, a myxoma appears as a mobile mass attached to the endocardial surface by a stalk, usually arising from the fossa ovalis  as was reported in the index case. Our patient awaits surgical intervention that is difficult to come by in most resource-limited countries.
| Conclusion|| |
Atrial myxoma is rare; it has varied clinical presentation and may be associated with clinical features of severe malnutrition especially if associated with heart failure.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]