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Akins PT. The sentinel rash and neurocutaneous presentation of atrial myxoma: Case report and literature review. Heliyon 2024; 10:e25387. [PMID: 38375268 PMCID: PMC10875371 DOI: 10.1016/j.heliyon.2024.e25387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/21/2024] Open
Abstract
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.
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Affiliation(s)
- Paul T. Akins
- The Permanente Medical Group, Department of Neurology Kaiser Sacramento Medical Center 2025 Morse Avenue Sacramento, CA 95825, USA
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Asif M, Yousuf MH, Farooqui US, Nashwan AJ, Ullah I. Cutaneous signs of selected cardiovascular disorders: A narrative review. Open Med (Wars) 2024; 19:20240897. [PMID: 38463529 PMCID: PMC10921438 DOI: 10.1515/med-2024-0897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/14/2023] [Accepted: 12/14/2023] [Indexed: 03/12/2024] Open
Abstract
Cardiovascular diseases are the leading cause of mortality and morbidity globally. Clinicians must know cutaneous signs of cardiovascular disease, including petechiae, macules, purpura, lentigines, and rashes. Although cutaneous manifestations of diseases like infectious endocarditis and acute rheumatic fever are well established, there is an indispensable need to evaluate other important cardiovascular diseases accompanied by cutaneous signs. Moreover, discussing the latest management strategies in this regard is equally imperative. This review discusses distinctive skin findings that help narrow the diagnosis of cardiovascular diseases and recommendations on appropriate treatment.
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Affiliation(s)
- Marium Asif
- Faculty of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | | | - Irfan Ullah
- Department of Internal Medicine, Khyber Teaching Hospital, Kabir Medical College, Gandhara University, Peshawar, Pakistan
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Ratzinger G, Zelger BG, Zelger BW. Bar Code Reader - an algorithmic approach to cutaneous occluding vasculopathies? part II medium vessel vasculopathies. J Dtsch Dermatol Ges 2020; 17:1115-1128. [PMID: 31765098 PMCID: PMC6899693 DOI: 10.1111/ddg.13973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Aims Classifications of occluding vasculopathies (except vasculitis [1]) may exhibit some difficulties. Firstly, classifications may follow different principles, e.g. clinicopathologic findings, etiology or pathogenesis. Secondly, authors may not distinguish between vasculitis and occluding vasculopathies. Thirdly, occluding vasculopathies are systemic diseases. Organ‐specific variations make morphologic findings difficult to compare. Moreover, subtle changes are recognized in the skin, but may be invisible in other organs. Our aim was to use the skin and subcutis as a tool and clinicopathological correlation as the basic process for classification. Methods and results We first differentiate in the skin between small and medium vessel occluding vasculopathies. Here we focus on medium vessel‐occluding vasculopathies. In the second step we differentiate the vessel subtypes. In the final step, we differentiate according to the time point of the coagulation/reorganization process and the involved inflammatory cells/stromal features. By applying the same procedure to the various entities and visualizing the findings in the style of bar codes, the overlaps and differences in the clinical picture as well as the histopathology become more apparent. Conclusions Occluding vasculopathies are often not separate entities, but reaction patterns and epiphenomena. Distinguishing them from vasculitides is crucial because of the differences in pathogenesis, therapeutic approach and prognosis.
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Affiliation(s)
- Gudrun Ratzinger
- Department of Dermatology, Venereology and Allergology, Medical University Innsbruck, Innsbruck, Austria
| | - Bettina G Zelger
- Department of Pathology, Medical University Innsbruck, Innsbruck, Austria
| | - Bernhard W Zelger
- Department of Dermatology, Venereology and Allergology, Medical University Innsbruck, Innsbruck, Austria
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Ratzinger G, Zelger BG, Zelger BW. Barcodeleser – ein algorithmischer Ansatz für okkludierende kutane Vaskulopathien? Teil 2: Vaskulopathien mittelgroßer Gefäße. J Dtsch Dermatol Ges 2019; 17:1115-1130. [PMID: 31765089 DOI: 10.1111/ddg.13973_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 03/27/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Gudrun Ratzinger
- Universitätsklinik für Dermatologie, Venerologie und Allergologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Bettina G Zelger
- Institut für Pathologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Bernhard W Zelger
- Universitätsklinik für Dermatologie, Venerologie und Allergologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
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Bois MC, Eckhardt MD, Cracolici VM, Loe MJ, Ocel JJ, Edwards WD, McBane RD, Bower TC, Maleszewski JJ. Neoplastic embolization to systemic and pulmonary arteries. J Vasc Surg 2018; 68:204-212.e7. [PMID: 29502997 DOI: 10.1016/j.jvs.2017.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/23/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Arterial neoplastic emboli are uncommon, accounting for <1% of thromboemboli in the current literature. Nonetheless, this event may be associated with significant morbidity and mortality. Herein, we report a series of 11 cases of arterial neoplastic emboli from a single tertiary care center along with a comprehensive review of the literature to date. The aim of this study was to document the incidence, clinical presentations, and complications of arterial neoplastic emboli as well as to highlight the importance of routine histologic examination of thrombectomy specimens. METHODS Pathology archives from a single tertiary care institution were queried to identify cases of surgically resected arterial emboli containing neoplasm (1998-2014). Histopathology was reviewed for confirmation of diagnosis. Patient demographics and oncologic history were abstracted from the medical record. Comprehensive literature review documented 332 patients in 275 reports (1930-2016). RESULTS Eleven patients (six men) with a median age of 63 years (interquartile range, 42-71 years) were identified through institutional archives. Embolism was the primary form of diagnosis in seven (64%) cases. Cardiac involvement (primary or metastasis) was present in more than half of the cohort. Comprehensive literature review revealed that pulmonary primaries were the most common anatomic origin of arterial neoplastic emboli, followed by gastrointestinal neoplasia. Cardiac involvement was present in 18% of patients, and sentinel identification of neoplasia occurred in 30% of cases. Postmortem evaluation was the primary means of diagnosis in 27%. CONCLUSIONS This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.
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Affiliation(s)
- Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Michael D Eckhardt
- Department of Pathology and Laboratory Medicine, University of Chicago, NorthShore University HealthSystem, Evanston, Ill
| | | | - Matthew J Loe
- Interventional Radiology, St. Paul Radiology, St. Paul, Minn
| | - Joseph J Ocel
- Diagnostic Radiology, Mercy Health Services-Iowa Corporation, Mason City, Iowa
| | - William D Edwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph J Maleszewski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.
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Quan K, Song J, Zhu W, Chen L, Pan Z, Li P, Mao Y. Repeated multiple intracranial hemorrhages induced by cardiac myxoma mimicking cavernous angiomas: a case report. Chin Neurosurg J 2017. [DOI: 10.1186/s41016-016-0068-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rodríguez Bandera AI, Stewart NC, Uribe P, Minocha R, Choi JYJ. Cutaneous embolism of an atrial myxoma. Australas J Dermatol 2015; 56:218-20. [DOI: 10.1111/ajd.12301] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 11/27/2014] [Indexed: 12/28/2022]
Affiliation(s)
- Ana Isabel Rodríguez Bandera
- Department of Dermatology; Hospital Universitario La Paz; Madrid Spain
- Department of Dermatology; Westmead Hospital; Sydney New South Wales Australia
| | | | - Pablo Uribe
- Department of Dermatology; Westmead Hospital; Sydney New South Wales Australia
- Department of Dermatology; School of Medecine; Pontificia Universidad católica de Chile; Santiago Chile
| | - Rashi Minocha
- Department of Dermatology; Westmead Hospital; Sydney New South Wales Australia
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Cardiac myxoma as a mimic: a diagnostic challenge. Am J Emerg Med 2014; 32:1399-404. [DOI: 10.1016/j.ajem.2014.08.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/14/2014] [Indexed: 12/25/2022] Open
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González-Suárez I, Rodríguez-Sanz A, Tallón-Barranco A, Diez-Tejedor E. Neurological focal signs as a first manifestation of cardiac myxoma. NEUROLOGÍA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.nrleng.2012.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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González-Suárez I, Rodríguez-Sanz A, Tallón-Barranco A, Diez-Tejedor E. Focalidad neurológica como primera manifestación de un mixoma cardiaco. Neurologia 2013; 28:384-5. [DOI: 10.1016/j.nrl.2012.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 02/23/2012] [Accepted: 03/01/2012] [Indexed: 10/28/2022] Open
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Affiliation(s)
- Engin Senel
- Clinic of Dermatology, Çankiri State Hospital, Çankiri, Turkey.
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Abstract
Cardiovascular diseases may affect multiple organ systems including the skin. By identification of specific cutaneous findings, dermatologists may be the first physician to diagnose an underlying cardiovascular disease. This article discusses a number of cardiac disorders with prominent skin findings in addition to general dermatologic signs suggestive of cardiovascular disease.
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Abstract
Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, Albany, NY 12208, USA.
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Mirkinson LJ, Ratnayaka K, Sable CA, Gaskin PRA. Carney complex presenting with Raynaud's phenomenon and erythematous macules of the extremities. Pediatr Cardiol 2006; 27:297-300. [PMID: 16501880 DOI: 10.1007/s00246-005-1238-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 12-year-old male presented with a 6-week history of apparent digital vasculitis with color changes of the distal fingers and erythematous macules of the palms and soles. Physical examination revealed skin findings of Carney complex and an abnormal cardiac examination. Echocardiography demonstrated a large left atrial mass, which caused partial obstruction during diastole and moderate mitral valve insufficiency. Surgical excision and pathological examination of the mass confirmed the presence of a large, peduculated myxoma. This case illustrates the presentation of Carney complex with left atrial myxoma as apparent vasculitis and Raynaud's phenomenon.
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Affiliation(s)
- L J Mirkinson
- Department of Rheumatology, George Washington University Medical Center, Children's National Medical Center, Washington, DC 20010, USA.
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Selkane C, Amahzoune B, Chavanis N, Raisky O, Robin J, Ninet J, Obadia JF. Changing management of cardiac myxoma based on a series of 40 cases with long-term follow-up. Ann Thorac Surg 2004; 76:1935-8. [PMID: 14667616 DOI: 10.1016/s0003-4975(03)01245-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiac myxoma is generally considered to be a surgical emergency. However, as a result of progress in echocardiography and the increasing age of the patients presenting with this disease, the clinical presentation has changed and the management of cardiac myxoma now needs to be reviewed. METHODS Between 1978 and 2001, 40 patients (16 men and 24 women) between the ages of 6 months and 82 years (mean age, 55.6 years) were operated on for cardiac myxoma. Signs of heart failure with pulmonary congestion (22%) or pulmonary embolism (20%) indicated a high-risk emergency situation in some cases, whereas, in other cases (58%), the patient's condition was stable and the clinical presentation was less worrying. However, the tumor was always removed within 24 hours of admission. Most cases of cardiac myxoma observed over the last decade correspond to stable forms, as echocardiography has revealed smaller tumors in generally elderly patients. RESULTS The postoperative mortality was 7.5% (3 patients). No patients were lost to follow-up, and the mean follow-up was 13.6 years. One patient was reoperated for recurrence 3 years postoperatively. Five patients required further cardiac surgery: three mitral valve replacements, one coronary artery bypass graft, and one angioplasty. The 15-year survival rate was 69%. CONCLUSIONS Myxoma tends to be observed in a more elderly and higher risk population, often at an early stage. The classic approach of emergency surgery is not always appropriate in these stable forms, allowing more thorough preoperative assessment of these patients.
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Val-Bernal JF, Acebo E, Gómez-Román JJ, Garijo MF. Anticipated diagnosis of left atrial myxoma following histological investigation of limb embolectomy specimens: a report of two cases. Pathol Int 2003; 53:489-94. [PMID: 12828617 DOI: 10.1046/j.1440-1827.2003.01504.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- J Fernando Val-Bernal
- Department of Anatomical Pathology, Marqués de Valdecilla University Hospital, Medical Faculty, University of Cantabria, Santander, Spain.
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