Lung and Subcutaneous Abscess in the Clinical Presentation of a Papillary Fibroelastoma (PFE)

Abstract

INTRODUCTION: Papillary fibroelastromas (PFEs) are the second most common cardiac tumor after myxomas. (1) While most patients are asymptomatic, complications include thromboembolic events, myocardial infarction and valvular dysfunction. It is thought that PFEs lead to thromboembolic events either by causing turbulent flow and subsequent embolic sequelae, or fragmentation and embolization of the tumor's friable fronds. We report a case of a patient presenting with a subcutaneous abscess extending from the lung cavity. Work up revealed a PFE of the pulmonary valve. To date, this is the first case of a PFE leading to lung infarction and subsequent right upper lobe lung abscess with extension to the subcutaneous area. CASE PRESENTATION: A 66-year-old male with no significant medical history presented to the emergency room with a painful right sternoclavicular mass. The patient had presented to the ER ten days prior with similar symptoms, and was given NSAIDs for musculoskeletal pain. Since then, the mass had grown from the size of a nickel to the size of a tennis ball. Chest x-ray revealed an air-fluid level in the right upper lung field. Chest CT revealed a lung abscess extending to the chest wall and involving the right sternoclavicular joint. Blood culture/CT-guided drainage of the abscess revealed streptococcus pneumoniae. A 2D echocardiogram revealed a 2x1 cm mobile pulmonic valve mass, presumed to be infectious endocarditis. Surgery was consulted. A mobile, gelatinous, encapsulated, friable mass with multiple fronds on anterior pulmonic valve leaflet was removed. The histological findings were found to be consistent with a PFE without signs of infection. A six-week course of IV antibiotics lead to complete resolution of the lung and subcutaneous abscess. DISCUSSION: We believe this patient's PFE eventually lead to asymptomatic embolic pulmonary infarction. Subsequent lung abscess directly penetrated the chest wall, forming a subcutaneous abscess. Although embolization from the right heart is rare, pulmonary embolism and infarction can occur (2,3). Although the streptococcus pneumoniae bacteremia had already cleared at the time of PFE removal, it is unlikely that septic embolization was the initial cause. CONCLUSIONS: We present an interesting clinical presentation providing evidence that right-sided PFEs could lead to serious embolic complications despite low incidence when compared to the left side. Antibiotic treatment alone is adequate for streptococcus pneumoniae lung and subcutaneous abscess. Tumor excision would provide a definitive diagnosis and eliminate recurrent embolic complications.