PMC6243360_01
(a) Transthoracic echocardiogram (parasternal long axis view) showing marked infiltration of the left atrium and both the ventricles by diffuse large B-cell lymphoma. (b) Transthoracic echocardiogram (apical four-chamber view) showing marked infiltration of the left atrium and both the ventricles by the diffuse large B-cell lymphoma. (c) Transoesophageal echocardiogram (three-chamber view) showing extensive infiltration of the left atrium and the ventricles by diffuse large B-cell lymphoma. (d) CT imaging of the thorax showing extensive lymphoma infiltration of the heart.
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In addition, the left atrium was lined with an echogenic speckled mass encroaching on the the mitral valve leaflets (Figure 1a-c; Supplementary Video A). CT scan of his thorax confirmed bilateral pleural effusion and an extensive abnormal soft tissue infiltrating the pericardium, much of the myocardium and the inferior portion of the left atrium, extending up to the aortic arch into the superior mediastinum (Figure 1d).
(a) CT of the thorax showing significant improvement in the appearance of the lymphoma following chemotherapy. (b) Transthoracic echocardiogram (parasternal long axis view) showing significant improvement in the appearance of cardiac chambers post chemotherapy.
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He responded very well to the first two cycles of chemotherapy, achieving remission echocardiographically and radiologically (Figure 2a,b; Supplementary Video B).
(a) Transthoracic echocardiogram (apical four-chamber view) showing a highly mobile thrombus in the right atrium attached to the pacing lead. (b) Transoesophageal echocardiogram (bicaval view) showing a highly mobile thrombus in the right atrium attached to the pacing lead.
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In addition, he also developed deep vein thrombosis in his left leg and thrombus attached to the pacing lead that required anticoagulation (Figure 3a,b; Supplementary Video C).
(a) Positron emission tomography showing an infiltrative mediastinal mass with very high intensity fludeoxyglucose uptake. (b) Chest X-ray showing a lobulated mass (lymphoma) at the left hilum associated with small left pleural effusion.
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A month after completing the chemotherapy, he re-presented with increasing breathlessness, low backache and chest discomfort and a positron emission tomographic scan confirmed a metabolically active mediastinal mass, which was consistent with recurrence (Figure 4a). Despite initial stabilization, he continued to deteriorate, and a repeat chest X-ray confirmed clear evidence of lymphoma progression (Figure 4b).