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.