Livedo reticularis developing simultaneously with a syncopal attack in a patient with atrial myxoma

The sentinel rash and neurocutaneous presentation of atrial myxoma: Case report and literature review

Introduction

Presenting symptoms of atrial myxoma are classically viewed as a triad of cardiac, embolic, and constitutional symptoms. Dermatologic manifestations are viewed as constitutional symptoms and have not received much attention.

Methods

Illustrative case presentation and literature review.

Results

I admitted a 28 y woman transferred to the comprehensive stroke center with an ischemic stroke treated with intravenous thrombolysis. She had a two year history of skin lesions in the hands/fingers and feet/toes/sole. Skin biopsies showed perivascular neutrophilic inflammatory dermatitis without skin vasculitis. Admission physical exam was notable for chronic skin changes on her hand and foot and an acute erythematous petechial rash over the right side of her face in the distribution of the right external carotid artery. MRI brain showed ischemia involving the right internal carotid artery territory. Transthoracic echocardiogram identified a 2.4 cm atrial myxoma with normal mitral valve function. She underwent uncomplicated cardiac surgery with confirmation of a villous myxoma. At her 8 week follow up visit, she had resolution of her neurologic deficits, and her skin rashes had cleared.Literature review identified 17 additional published cases of sentinel rashes preceding diagnosis of atrial myxoma. Skin changes were often reported in the hand and feet and may involve the digits, palm, and sole. In 8 cases, skin biopsy identified myxomatous emboli in dermal vessels. These cutaneous manifestations share similarities with Osler nodes and Janeway lesions first described in the 1890's, now understood to represent microemboli to the dermis. Seven of these 17 cases (41 %) developed strokes after the initial presentation of cutaneous changes. Our patient had an embolic event primarily affecting the right common carotid artery territory with facial cutaneous changes due to emboli to the external carotid artery territory and cerebral ischemia in the right internal carotid artery territory.

Conclusion

I recommend reclassification of the cutaneous signs of atrial myxoma as embolic (to the dermis microvasculature) rather than a constitutional symptom. As the skin biopsy often fails to show myxomatous emboli, physicians should have a high suspicion for a proximal embolic source for patients with a migratory rash preferentially affecting distal extremities. Earlier diagnosis of atrial myxoma when the sentinel rash first appears provides a valuable window of opportunity for cardiac surgery before the patient experiences stroke or peripheral emboli.

Unusual cause of infective endocarditis in an elderly patient with a rare condition

A 77-year-old woman presented to the emergency department with a 1-week history of anorexia, fatigue, general malaise and a 3-day history of fever. Clinical examination revealed livedo reticularis across the anterior aspect of her knees and a pansystolic murmur. Laboratory evaluation found neutrophil leucocytosis; elevated C reactive protein and blood cultures grew Streptococcus acidominimus. Transthoracic echocardiography displayed vegetation on the mitral valve and a left atrial myxoma. She was treated with intravenous benzylpenicillin and erythromycin for the infective endocarditis (IE) and remains well 3 months post-treatment. S. acidominimus is considered a common veterinary pathogen rarely found in humans. To the best of our knowledge, only two prior reports of IE due to this organism exist in the literature. This case highlights how rare pathogens can cause unusual presentation and the importance of IE as a differential even in the absence of classical signs, if fever and new murmur are present.

Cardiac myxoma induced paraneoplastic syndromes: a review of the literature

BACKGROUND

Atrial myxomas are the most common benign tumors of the heart and may present with a wide variety of symptoms. Although 45% of patients present with neurological symptoms, a diverse range of systemic symptoms also occur.

METHODS

A systemic review of the literature related to the diagnosis, treatment, pathogenesis, and symptoms associated with atrial myxomas was performed.

RESULTS

Here we summarize the current state of understanding about myxoma pathogenesis and treatments are described. We review the common and rare local and systemic effects of myxomas. Additionally, we review the paraneoplastic and metastatic potential of myxomas.

CONCLUSIONS

A better understanding of the diverse disease presentations, paraneoplastic syndromes, and side effects of cytokine abnormalities stemming from myxomas will aid the physician in earlier detection and monitoring of disease recurrence.

Livedo reticularis: An update

Livedo reticularis (LR) is a well-known, relatively common physical finding consisting of macular, violaceous, connecting rings that form a netlike pattern (Fig 1). In most cases, it is a completely benign finding related to cold exposure. However, there are many potential causes (Table I), and this can make the evaluation of a patient presenting with this finding very difficult. An excellent review of the topic by Fleischer and Resnick was published in 1990. We have endeavored to update the literature and provide clinicians with guidance regarding the evaluation and treatment of patients presenting with LR.

Anticipated diagnosis of left atrial myxoma following histological investigation of limb embolectomy specimens: a report of two cases

Nonfamilial myxoma occurs as a random event. The tumor is rare and can mimic other diseases. Cardiac myxomas should always be considered as a source of embolization, which need meticulous investigation and prompt indication of surgical resection. Tumors with a villous surface are prone to embolize. We report two cases of cardiac myxoma presenting as acute ischemia of one or two limbs due to embolic phenomena. The patients were females aged 55 and 37 years. Histological study of emboli taken from obstructed limb arteries in the two patients showed a picture indicating systemic embolization of a cardiac myxoma. The embolic tissue fragments showed the gross characteristics (i.e. villous surface) of the cardiac tumor. Further echocardiography and surgical removal confirmed the cardiac myxoma. Immunohistochemical study of embolectomy material disclosed strong reactivity of the tumor cells for calretinin. The histological examination of the embolectomy material can anticipate the cardiac lesion and its gross features. Calretinin is a useful marker in the differential diagnosis of cardiac myxoma with a myxoid thrombus. The necessity of histological examination of the embolectomy material is stressed.

Cutaneous embolization of cardiac myxoma

Atrial myxoma is the most common primary tumour of the heart. Skin manifestations in patients with a cardiac myxoma are frequent and may be due to cutaneous emboli, or may be specific findings as part of more complex syndromes. We present a 33-year-old-man with a history of episodes of pain in both legs and an ischaemic neurological event, who also had episodes of acral papular erythematous lesions on the legs and feet including the soles. The histological finding of dermal vessels occluded by a myxomatous material was the clue to the diagnosis of a cardiac myxoma. The diagnosis of this entity can be very difficult, because of the broad spectrum of clinical features; rarely the skin manifestations lead to the diagnosis of this tumour. The histological recognition of the myxomatous emboli is of vital importance for the diagnosis and treatment of this disease.

Erythematous papules in a patient with cardiac myxoma: a case report and review of the literature

A 35-year-old woman was followed up by a physician for one and a half years as a case of transient ischemic attach (TIA) due to thrombosis. She had a few erythematous papules on the dorsal side of her right forearm and on the right side of her neck. From the history of TIA and the transient erythematous papules, we suggested the possibility of cardiac myxoma. Echocardiogram demonstrated a large mass in her left atrium. An immediate operation was carried out, and the cardiac myxoma was excised surgically. Histological examination of the erythematous papule revealed myxoma emboli.

Atrial myxoma with livedoid macules as its sole cutaneous manifestation

We report the second case of atrial myxoma associated with livedoid macules representing an embolic phenomenon. This case of atrial myxoma was of the sporadic type with no associated syndrome (such as the LAMB or NAME syndrome or Carney complex). A skin biopsy specimen from fading livedoid macules on the extremities showed a myxoid embolus inside dermal vessels, a diagnostic clue to the presence of an atrial myxoma. The histologic features of such lesions should alert the clinician to the presence of an otherwise silent atrial myxoma. Early surgical intervention may prevent the onset of severe neurologic deficits in such patients.