CHEST Guidelines-A-51-Year-Old-Man-With-Right-Atrial-Neoplasm-Prese

A-51-Year-Old-Man-With-Right-Atrial-Neoplasm-Prese

Pdf Summary

A 51-year-old man with a long history of psychosis and recent hospitalization following an assault presented with syncope and shock after commencing antipsychotic medication. His condition worsened with hypotension and hypoxia, leading to ICU admission. Initial tests revealed elevated white blood cells, liver enzymes, D-dimer, and troponin levels, suggesting a state of inflammation or stress.<br /><br />An emergent bedside ultrasound identified a massive echogenic mass in the right atrium, obstructing blood flow and causing tricuspid regurgitation. A CT pulmonary angiography confirmed the presence of large thrombi in the right atrium and multiple pulmonary arteries, indicating cardiac emboli and pulmonary embolism.<br /><br />The presence of a thrombus in the right atrium led to speculations about its origin, likely linked to the recent initiation of antipsychotic medications such as quetiapine, known to elevate the risk of venous thromboembolism, especially in elderly and immobilized patients. The absence of organic heart disease pointed towards embolic thrombus rather than an in-situ formation.<br /><br />Treatment involved the use of anticoagulants like heparin and alteplase, and the patient showed significant improvement, with the right atrial mass disappearing and cardiac function stabilizing. This case underscores the critical role of point-of-care ultrasound (POCUS) for rapid diagnosis in emergencies, facilitating swift therapeutic decisions. <br /><br />Echocardiography was pivotal in differentiating cardiac masses, though similarities between thrombi and myxomas exist. Right atrial thrombi with concurrent pulmonary embolism have a grave prognosis, highlighting the need for precise imaging and timely intervention. Despite therapeutic risks, including thrombus displacement, management with anticoagulation and thrombolytics crucially addressed the patient's life-threatening condition, allowing discharge after significant recovery.

Keywords

psychosis

antipsychotic medication

syncope

right atrial thrombus

pulmonary embolism

anticoagulation

point-of-care ultrasound

quetiapine

echocardiography

thrombolytics