Biventricular thrombi in a patient with methamphetamine induced dilated cardiomyopathy

Abstract

A 39-year-old male with a 20-year history of cannabis and methamphetamine abuse presented to the ER with progressive shortness of breath, orthopnea, and bilateral leg swelling.Temperature 36.8°C, pulse 116/min, blood pressure 125/89 mmHg, respiratory rate 18/min, oxygen saturation 93% on room air. He had 2+ bilateral pitting pedal edema, elevated JVD, and S3. He had elevated BNP and creatinine, low magnesium, and potassium. UDS was positive for Amphetamine and THC (Marijuana) but normal Ethanol level. EKG was sinus rhythm, PVCs, and non-specific T wave changes; CXR showed cardiomegaly with pulmonary vascular congestion. CT chest revealed an indeterminate well-circumscribed filling defect in the right ventricle’s apex concerning for a thrombus versus neoplastic nodule. Transthoracic Echocardiography (TTE) findings of biventricular dilatation, global hypokinesis, right and left apical thrombus, a 5 X 3.2 cm mass in the right ventricle, Left Ventricular Ejection Fraction (LVEF) of 15 to 20%, grade 2 diastolic dysfunction, and Pulmonary Artery Systolic Pressure (PASP) of 40 mmHg (Figure 1a & 1b). He had widely patent coronary arteries on left heart catheterization, but Right heart catheterization showed elevated pulmonary capillary wedge pressure. Thrombophilia screen was negative, and there was no Deep Venous Thrombus (DVT) on lower extremity venous Doppler ultrasound.