PA26.{8,10} | Pericardial Disease & Cardiac Tumours — Summary & Reflection

REFLECT

Consider a 60-year-old woman with a 3-month history of fever, weight loss, and progressive dyspnoea. She has a new early diastolic sound and signs that initially suggest mitral stenosis, but echocardiography reveals a mobile left atrial mass. She also has two episodes of sudden right arm weakness that resolved within hours.

1. What is your most likely diagnosis and why?
2. Which two clinical complications has she already developed?
3. How does the histological appearance of this lesion differ from an angiosarcoma arising in the same chamber?
4. If this were a 70-year-old woman with known breast carcinoma, how would your diagnostic hierarchy change, and why?

KEY TAKEAWAYS

Pericardial Disease
• Pericarditis aetiology: viral (commonest, self-limiting), TB (constrictive risk), pyogenic (purulent), immune (rheumatic, SLE, Dressler, uraemic), neoplastic
• Six morphological types: serous → fibrinous (bread-and-butter, classic) → serofibrinous → purulent → haemorrhagic → caseous (TB)
• Pericardial effusion: serous (transudate), serosanguineous, chylous — rate of accumulation determines haemodynamic effect
• Cardiac tamponade: rapid accumulation → ↑ intrapericardial pressure → ↓ RV/LV filling → obstructive shock; Beck's triad (hypotension, ↑JVP, muffled sounds); pulsus paradoxus >10 mmHg; treatment = pericardiocentesis
• Constrictive pericarditis: TB commonest cause in India; dense fibro-calcific encasement; pericardiectomy

Cardiac Tumours
• Metastases >> primary (20–40:1); lung, breast, melanoma, lymphoma commonest sources
• Benign primary: myxoma (left atrium, gelatinous, myxoma cells in myxoid stroma, ball-valve obstruction, embolism, constitutional); rhabdomyoma (children, tuberous sclerosis, spider cells); papillary fibroelastoma (valves, embolic risk)
• Malignant primary: angiosarcoma (right atrium, haemorrhagic, poor prognosis)

Vascular Tumours
• Haemangioma (benign): capillary, cavernous, pyogenic granuloma
• Glomus tumour: painful, subungual, glomus cells
• Kaposi sarcoma: HHV-8, AIDS commonest form, spindle cells + slit-like spaces + haemosiderin
• Angiosarcoma: endothelial malignancy; liver (vinyl chloride), breast/skin (post-irradiation/lymphoedema), heart (right atrium)