Case Presentation
A 32-year-old male with no significant medical history presented to our
Internal Medicine department with a history of constitutional symptoms
that were associated with atypical left-sided chest pain, which led to
the diagnosis of extrapulmonary tuberculosis based on symptoms and chest
radiography findings (Fig. 1). He was kept on antituberculous drugs for
two weeks without improvement. He denied a history of headache, visual
disturbance, convulsions, loss of consciousness, or abdominal pain. He
denied a history of headache, visual disturbance, convulsions, loss of
consciousness, or abdominal pain.
Two weeks before the diagnosis of extrapulmonary tuberculosis, he was
attended at the ophthalmology clinic with a six weeks history of a
moderately growing mass on the left lower lid that was painless and
itching. On local examination, there was a nodule on the right lower
eyelid arising from the inferior tarsal conjunctiva with skin-colored to
erythematous, measuring 3cm x 3cm. Excision biopsy of the nodular mass
was done for histopathological evaluation.
On examination, he was not wasted with stable baseline vital signs. He
had a left peri-nostril mass measuring 1 cm x 1 cm, which bled easily to
touch. On chest examination, he had non-tender left anterior chest wall
swelling at the level of the third rib. The mass was firm and mobile,
measuring 8 cm x 8 cm. There were crackles on the left infra-scapular
area. The incisional biopsy was taken from the anterior chest swelling
on the left mammary area.
Hematological parameters revealed an elevated erythrocyte sedimentation
rate of 79 mm/hr, rest of blood cell lines, urea, creatinine,
electrolytes, and liver function tests were normal. The HIV infection
serology and sputum for TB tests (Acid Fast Bacilli and GeneXpert) were
negative. The chest x-ray revealed bilateral diffuse pulmonary nodular
lesions and prominent lobulated right cardiac margin features suggestive
of middle mediastinum mass with metastatic pulmonary lesions. Contrasted
Chest CT (Fig. 2a) was performed and showed soft tissue heterogeneously
enhancing lobulated mediastinal mass extending into the Right Atrium
(RA) with associated diffuse pulmonary and pleural nodular lesions while
Head CT (Fig. 3a) showed ring-enhancing lesions with surrounding edema
involving the right frontal lobe consistent with metastatic lesions.
Contrasted abdominal pelvic CT (Fig. 2b) was performed two weeks later
and showed multiple enhancing hypodense hepatic lesions with the scanned
part of the chest, showing increased pulmonary nodules consistent with
rapid disease progression. There was also bone involvement (Fig. 3b)
Transthoracic echocardiography (Fig. 4) revealed a large anterior mass
that was compressing and infiltrating the right atrium. Also noted were
multiple right atrial masses with one mobile mass moving through
tricuspid valves leaflets. Masses were of variable sizes largest
measuring and heterogenous echogenicity causing mid-right atrium and
tricuspid valve pseudostenosis with a significant mean pressure gradient
of 12.9 mmHg. The rest of the echo study was normal with preserved left
ventricle ejection fraction (LVEF) of 70%.
This patient was admitted to the medical ward. While in the ward, He
developed shortness of breath with a respiratory rate of 25 bpm, heart
rate of 102 bpm, but maintained normal saturation on room air of 93%.
We had a concern about probable pulmonary embolism based on the clinical
background and echo findings. He was, in the meantime, started on a full
dose of unfractionated heparin with reasonable improvement from his
shortness of breath.
The histopathological results of the excised conjunctival mass and
incisional biopsy on the left mammary area showed features suggestive of
angiosarcoma (Fig. 5)
Due to the evidence for advanced metastasis, the patient and the
relatives were involved in the discussion of the possible treatment
options available. However, the family requested to be discharged for
home-based palliative care. Unfortunately, the patient demised one week
after discharge from the hospital.