PMC9284981_01
(A) Friable erythematous nodule of left medial leg. (B) Sagittal positron emission tomography with computed tomography with avid uptake in the same nodule of left leg (arrow).
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F1
A 71-year-old immunocompetent male with a dual-chamber pacemaker presented with 2 months of fevers, chills, weight loss, and new cutaneous nodules (Figure 1 A).
(A) Mass-like right atrial filling defect (arrow) demonstrated on transverse contrast computed tomography (CT). (B) Right atrial mass (arrow) redemonstrated on sagittal contrast CT encasing pacemaker leads. (C) Prechemotherapy positron emission tomography with computed tomography (PET-CT) demonstrating avid uptake of a right atrial mass (arrow) encasing pacemaker leads in transverse view. (D) PET-CT demonstrating complete metabolic response (arrow) post-treatment in transverse view.
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F2
A, B). A fluorodeoxyglucose (18F-FDG) positron emission tomography with computed tomography (PET-CT) revealed a region of avid uptake in the right atrium adjacent to pacemaker leads, suggestive of a possible infected thrombus (Figure 2 C). In clinic follow-up, he initially demonstrated complete metabolic response on post-treatment PET-CT (Figure 2 D).
(A) Apical four-chamber view on transthoracic echocardiogram did not show any evidence of mass or thrombus in the RA. (B) Mid-esophageal bicaval view on transesophageal echocardiogram shows the mass extending from the superior vena cava into the RA along the device lead. RA: right atrium; LA: left atrium; IVC: inferior vena cava; M: mass; SVC: superior vena cava
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F3
A). A subsequent transesophageal echocardiogram (TEE) revealed a 4.9 cm x 4.0 cm x 2.3 cm mass in the superior vena cava and right atrium engulfing the right atrial and right ventricular pacemaker leads (Figure 3 B).
(A) Gadolinium cardiac magnetic resonance imaging in transverse view showing heterogeneous hyperenhancement of right atrial mass (arrow) occupying the right atrium, with right ventricle, left atrium, and left ventricle. (B) Same right atrial mass (arrow) redemonstrated in sagittal view with RV and aorta. RA: right atrium; RV: right ventricle; LV: left ventricle; LA: left atrium; Ao: aorta
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F4
Cardiac magnetic resonance imaging (CMR) with gadolinium was obtained for mass characterization, which demonstrated heterogeneous hyperenhancement suggestive of malignancy (Figure 4).