A 48-year-old female with a past medical history of opioid use disorder on suboxone presents with abdominal pain for one day. The patient developed sharp diffuse upper abdominal pain the evening prior to arrival that resolved. The pain recurred again today and was associated with bilious emesis. The patient notes persistent upper abdominal pain with paroxysmal exacerbation. She has a history of a hysterectomy, but no other abdominal surgeries. No history of gallstone pathology.

Vitals: HR 38; BP 120/63; RR 14; SpO2 100%

HEENT: No jugular venous distention, no scleral icterus.

CV: Normal S1, S2, regular rhythm.

Respiratory: Clear breath sounds bilaterally.

Abdominal: Mild tenderness to palpation in the epigastrium, without rebound or guarding.

Extremities: Warm and well perfused, no edema.

White blood cell (WBC) count: 11

Alk phos: 123

Total Bilirubin: 0.5

Lipase: 24

Troponin: 0

Lactate: 1

An echo was performed for bradycardia and a brief episode of hypoxia in the emergency department. A large, tethered mass is seen likely originating from the left atrium. This finding is most consistent with an atrial myxoma, though it can also represent a clot. The patient was ultimately diagnosed with gallstone ileus and an atrial myxoma.

Take-Home Points

  • Myxomas are the most common type of cardiac mass. They occur more commonly in females, arising between the fourth and sixth decade of life. They are most commonly located in the left atrium.
  • Patients can experience obstructive and thromboembolic symptoms. Distal embolic events can cause neurologic deficit, visceral ischemia, STEMI, and limb ischemia amongst other critical presentatations.
  • Bernatchez, J., Gaudreault, V., Vincent, G., & Rheaume, P. (2018). Left atrial myxoma presenting as an embolic shower: a case report and review of literature. Annals of vascular surgery, 53, 266-e13.
  • Nguyen T, Vaidya Y. Atrial Myxoma. 2022 Jul 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32310500.

Kelly Dougherty, MD

Kelly Dougherty, MD

Resident Physician
Department of Emergency Medicine
Temple University Hospital
Kelly Dougherty, MD

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