Sudden dyspnea and syncope episode in a 38-year-old female.

Dr. Tomaso Bottio, Dr. Aldo Milano. A 34-year-old female (165 m, 55 kg), with no medical history, nor smoking, alcohol consumption, allergies, or surgical events, visited the emergency department of a peripheral hospital for dyspnea, tachycardia, and a single episode of syncope. On examination, blood pressure was 95/65 mmHg and heart rate 95 bpm. Laboratory tests were normal with no D-Dimer elevation. The ECG showed no abnormalities on ST segment. The chest was clear to auscultation, and she had a reduction of all four heart sounds. Dr. Fischetti (resident): Was a chest X-ray or echocardiogram done? Dr. Bottio and Milano: Chest X-ray shows a second left arch heart profile enlarged. The echocardiogram shows heterologous mass in the pericardial space with moderate–severe effusion. The right ventricular outflow tract (RVOT) is almost totally occluded by a solid mass, and both pulmonary trunk and branches are involved. The right ventricle is severely dilated, and its function is depressed. Left ventricle function and dimension are normal (EF 50%). Dr. Giovannico (resident): It looks like a cancer. Was a CT scan done? Dr. Bottio and Milano: CT scan, done elsewhere, showed the presence of a large mass likely to originate from the pulmonary artery wall that extends intravascularly into the right ventricular outflow tract and proximal pulmonary arteries and extravascularly in the left atrioventricular sulcus and along the lateral wall of the ventricle left. The lesion encompasses the common trunk of the left coronary artery, the bifurcation, and the proximate portion of the anterior interventricular and circumflex arteries. Pericardial effusion was evident too. Dr. Domenico Parigino (resident): In the strong suspicion of malignancy, I suggest to carry out a magnetic resonance imaging (MRI) to evaluate the mass relationships with the surrounding cardiac and mediastinal structures. In addition, it would be advisable to exclude metastatic foci.