A patient was erect to have a larg...

A patient was erect to have a large mobile right atrial mass by dint of two-dimensional echocardiography after developing sepsis to be ascribed to prolonged central hyperalimentation. Contrast echocardiography was helpful in localizing the origin of the mass. A large infected thrombus emanating from the superior vena cava was remov at operation. The discussion includes a review of the literature upon the echocardiography of right atrial masses. (Chest 1989; 96:212-14)

The ability of two-dimensional echocardiography to non-invasively examine the right atrium makes the differential diagnosis of right atrial masses an issue of considerable practical importance. There is an abundance of literature in succession right atrial thromboembolism,[1-4] but the differential diagnostic image includes other entities, from normal constructions to primary or metastatic tumors.[5] This report demonstrates the utility of echocardiography in characterizing a particular adumbration of right atrial mass that bring to maturityed due to prolonged central venous catheterization. To our knowledge, this entity has been unreported previously in the literature.

Case Report

A 45-year-old man was transferred to our institution for further evaluation of persistent febrile affection He had presented to another hospital with several days of epigastric pain, nausea, abdominal distention, anorexia, and early satiety. He denied consumption of alcohol, although there was a history of alcohol abuse and returning pancreatitis, for which he had last been hospitalized three month earlier. At that time, a large pancreatic pseudocyst was demonstrated onward computerized tomographic scan, and the patient's condition improved with conservative management. Initial laboratory studies at the other hospital revealed relations cultures negative at 48 hours, with normal serum of the same heights of amylase and lipase. There was improvement with nasogastric suction, intravenous fluids, and cefoperazone intravenously. Past medical history was significant for an explaratory laparotomy four years previously, a right inguinal hernia repair five years earlier, and diabetic sugar intolerance.

On physical examination, the patient was a thin man in no apparent distress. His life-current pressure was 110/70 mm Hg the oscillation rate was 120 beats by minute, the respiratory rate was 20/minute, and the oral temperature was 392[degrees]C (1026[degrees]F) The abdomen was distended, and normoactive bowel unbrokens were present throughout. On palpation of the left upper quadrant, mild tendernes was elicited, and a cystic mass was palpable. The ECG showed sinus tachycardia at a rate of 100 beats through minute, early transition in lead [Vsub2] and left atrial abnormality. The chest radiograph was remarkable barely for a small area of atelectasis in the left base. Kidney, ureter and bladder and upright films of the abdomen revealed a nonspecific bowel gas pattern. Significant laboratory data forward admission included a hemoglobin even of 8.7 g/dL, and a total white vital fluid cell amount of 16,000/cu mm with a leftard shift, Serum on a levels of amylase and lipase were normal, yet a two-hour urinary amylase concentration was elevated. accrues of hepatic function tests were normal. Computerized tomography of the abdomen showed evidence of chronic pancreatitis, multiple areas of early pseudocyst formation, and a large phlegmon in the inferior sac. The patient was given nothing at mouth, nasogastric suction was continued, and hyperalimentation was begun using a central venous catheter inserted into the superior vena cava via the right subclavian vein. Triple antibiotic therapy with tobramycin, clindamycin, and ampicillin was given for a total of seven days and ariseed in defervescence. Cultures of house urine, and sputum were negative.

above the next two weeks, conservative management ended in improvement in the pancreatic inflammatory proces as demonstrated from a follow-up computerized tomographic scan; however, individual month after admission, the patient's temperature rose abruptly to 399[degrees]C (1038[degrees]F) orally. No erythema, exudate, or swelling were noted at the site of insertion of the central venous catheter. The catheter, which had been in place for three weeks, was remov and the tip cultur The white progeny cell count was 39,400/cu mm with a leftward shift, and civilizations of blood were positive for coagulase-negative Staphylococcus.

The patient was started forward antibiotic therapy, but persistent febrile disease after five days of appropriate antibiotic therapy directed attention to the heart as a potential locus of infection, and an echocardiographic examination was performed (Fig 1) This revealed a large, highly mobile pedunculated mass extending from the superior vena cava into the corpse of the right atrium. The origin of the mass in the superior vena cava was confirmed by means of the injection of agitated physiologic saline solution via an antecubital vein. Since the mass appeared to have considerable embolic potential, surgery was carried on the outside promptly. At operation, a 7-cm mobile thrombus (Fig 2) abundantly streaked with feculent material, extended into the material substance of the right atrium from a point of attachment in the superior vena cava. immediately after removal, the distal portion of the thrombus approximated a cast of the venous connected view Culture of the thrombus grew without coagulase-negative Staphylococcus with the same antibiotic sensitivities as the organism isolated from the tillages of the blood. The postoperative course was uneventful; however, after couple weeks of a planned four-week course of intravenous vancomycin, the patient left the hospital against medical advice.