Myocardial Infarction With Intracardiac Thrombosis as the Presentation of Acute Promyelocytic Leukemia

Abstract

A 29-year-old woman presented in February 2010 with acute-onset severe chest pain. This radiated to the left shoulder and was associated with breathlessness. She was afebrile, her saturations were 100% on air, and her clinical examination was entirely normal. An electrocardiogram showed diffuse 2- to 3-mm ST-segment elevation. At presentation, troponin I was elevated at 2.4 ng/mL (normal <0.1 ng/mL). Full blood count, chest radiograph, arterial blood gas, and bedside echocardiogram were unremarkable. She was diagnosed with myopericarditis and discharged from the accident and emergency department with nonsteroidal anti-inflammatories. Two days later, she returned with worsening chest pain and was admitted for investigation. She had a full blood count, and urea and electrolytes were within the normal range. Troponin I was significantly elevated at 15.2 ng/mL, C-reactive protein was >160 mg/L (normal 20 000 μg/L (normal 0 to 500 μg/L). Her electrocardiogram showed further widespread ST elevation, and repeat bedside echocardiogram demonstrated a mass at the left ventricular apex, with apical hypokinesis (Figure 1 and online-only Data Supplement Movie I). A cardiac magnetic resonance scan revealed apical scarring consistent with a small myocardial infarct, with adherent apical thrombus in both the left and right ventricles (Figures 2 and 3 and online-only Data Supplement Movies II and III). Figure 1. A, Electrocardiogram showing diffuse ST-segment elevation. B, Transthoracic echocardiogram: apical 4-chamber view in systole showing …