The Disappearing Cardiac Mass

Abstract

INTRODUCTION: Hiatal hernias are frequently found incidentally by radiologists and gastroenterologists. Incidence increases with age. Increased intra-abdominal pressure is thought to predispose patients to hiatal hernias. CASE PRESENTATION: The patient is a19 year old female who is at 27 weeks gestation who presents with a two day history of chills, fevers, and cough productive of green sputum. Initial vitals include: blood pressure 106/62, pulse 120(regular), respiratory rate of 20, temperature 101.3 F, oxygen saturation of 96% on room air. The patient was awake, alert, and oriented, and physical examination was normal, except for moderate wheezing in all lung fields. Her abdominal exam displayed normoactive bowel sounds, and was nontender, and appropriate size for gestational age. Routine labs including a complete blood count, routine chemistry, and urinalysis was within normal limits. An EKG showed sinus tachycardia with 126 beats per minute. Lactate was 3.1 mmol/L. The patient was given a total of six liters of normal saline with minimal response in blood pressure(systolic blood pressure 80s, heart rate 130s). The patient was admitted to the medical intensive care unit for management of possible severe sepsis and started on treatment for influenza A and possible superimposed pneumonia with oseltamivir, ceftriaxone, and azithromycin. Noninvasive fetal testing showed normal fetal activity. Echocardiogram results showed a normal left ventricular size and configuration, LVEF of 75%, and showed the presence of a large heterogenous mass adherent to lateral wall of pericardium. A repeat echocardiogram on day six of hospitalization was obtained and showed: normal left ventricular systolic function and the mass along the lateral wall of the left ventricle seen in the previous echocardiogram is no longer visualized. The patient continued to improve and was discharged. DISCUSSION: In 1985, Nishimura, et. al. were the first to report that hiatal hernia can simulate a left atrial mass on 2-D sonographic imaging by encroaching on the posterior aspect of the left atrium, and posterior to the left atrioventricular junction. Most patients are managed by lifestyle modification or with proton pump inhibitors or H2 receptor blockers. Examples of patients in whom surgery would be considered include: those with complications of reflux esophagitis, have chest pain, or have a risk of strangulation. CONCLUSIONS: The patientas unresponsiveness to IV fluids, and the hypotension itself likely occurred during the time the hernia compressed the cardiac ventricles. This case also shows the importance of re-evaluating or considering repeat diagnostics.