The Use of Contrast Echocardiography to Identify Infiltrating Lymphoma in the Myocardium

Abstract

Introduction Echocardiographic contrast agents are approved by the US Food and Drug Administration (FDA) for delineation of the LV endocardium however its role in the assessment of myocardial disease has not been defined [1]. Contrast echocardiography has demonstrated an ability to better differentiate myocardial tissue with respect to myocardial blood flow. Ultrasound contrast agents have been demonstrated to be useful in differentiating thrombi from benign and malignant neoplasms that are confined to the endocardium [1,2]. We present a clinical example where non-contrast and contrast enhanced echocardiograms demonstrated remarkably different myocardial compositions. In our patient, contrast enhanced echocardiography identified infiltrating lymphoma in the myocardium that was not seen with standard 2D imaging. Case Description 68 year-old African American man, with a past medical history of AITL and hepatitis C virus, presented with 2 weeks of weakness and fatigue. Symptoms were associated low grade fevers, but were non-exertional and not associated with chest pain, shortness of breath, dyspnea on exertion or cough. Medical history included AITL with autoimmune hemolytic anemia, initially diagnosed 3 years prior to admission. Patient completed CHOP (Cyclophospharmide/Doxorubicin/Vincristine) Chemotherapy. He was in remission until 2 months prior to this admission; at which point he was found to have recurrence in his right axillary lymph node and was started on ICE (Ifosfamide/Carboplatin/Etoposide). There was no known history of cardiovascular disease. Physical exam revealed tachycardia, positive jugular venous distention, bibasilar crackles on pulmonary exam, and +1 pitting peripheral edema. Cardiac exam displayed regular rate and rhythm, with normal S1/S2 but cardiac sounds were muffled. Labs showed a BMP within normal limits. CBC revealed a leukocytosis (Wbc=23.8 10xe3/mm3) with a left shift with a new anemia (Hgb of 8.5 g/dl) and thrombocytopenia (Plt=67 10xe3/mm3). Additionally, a BNP=442 pg/ml and Trop=0.12 ng/ml