A case of complete heart block reverting to normal sinus rhythm after treatment for cardiac invasive Burkitt’s lymphoma

Abstract

Dear Editor, A 42-year-old man was transferred to our hospital after presenting with syncope. Approximately 3 and 6 weeks before admission, the patient had been involved in two separate fights resulting in significant facial injury and swelling. The patient did not seek immediate medical attention but persistent pain prompted evaluation at our hospital 10 days before the relevant admission. At that time, a computed tomography (CT) of the head and facial bones demonstrated facial fractures and an expansile opacification of the right maxillary sinus with erosive change of the adjacent osseous structures and contiguous abnormal soft tissue extending into the periantral fat and extraconal orbit (Fig. 1a). The radiographic differential was an infected mucocele with concomitant osteomyelitis versus a neoplastic process, and thus, biopsy was recommended. The patient was taken to the operating room, and a biopsy of the mass was performed. He was given antibiotics for a presumed infected mucocele with osteomyelitis and discharged with plans to follow-up in 1 week as an outpatient for the pathology results. Before his follow-up appointment, he presented to an outside hospital with complaints of syncope with pre-syncopal dizziness. By this time, the pathology results from the initial maxillary biopsy had revealed sheets of tumor composed of primitive cells with round hyperchromatic nuclei and prominent nucleoli (Fig. 2). Numerous large cells with clear cytoplasm were scattered through the tumor in a starry-sky-type pattern. The tumor appeared to be proliferating rapidly with frequent mitoses and geographic areas of necrosis. Immunohistochemical staining indicated B-cell lineage with aberrant CD10 coexpression and an extremely high proliferative index. The in situ hybridization study for Epstein Barr virus (EBV) genome was positive. Together, the findings were consistent with a diagnosis of Burkitt’s lymphoma. He was transferred to our hospital for further management. At the time of transfer, the patient was disheveled but in no acute distress. Before the diagnosis of the facial fracture, his medical history had been unremarkable other than surgical repair of an inguinal hernia. He was not taking medications other than acetaminophen and hydrocodone for pain and amoxicillin/clavulanate since his recent discharge. He had a complicated social history. He had been previously married but was divorced and was currently homeless. In the 1 to 3 years before admission, he had unprotected sexual intercourse with both men and women. He denied injection drug use but admitted to heavy alcohol use, as well as recreational cocaine and marijuana. He had smoked one to two packs per day for 27 years. His blood pressure was 123/67 mmHg, and his pulse was bradycardic in the 50 s. His physical exam was notable for a left-eye periorbital ecchymosis and right temple edema without ecchymosis, status post surgical incisions. He had bilateral mild axillary lymphadenopathy but no other evidence of lymph node enlargement. Cardiovascular exam was notable for a regular, bradycardic rhythm without murmur, gallop, Ann Hematol (2007) 86:687–690 DOI 10.1007/s00277-007-0290-x