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BMJ Case Rep. 2010; 2010: bcr0520103018.
Published online Sep 29, 2010. doi:  10.1136/bcr.05.2010.3018
PMCID: PMC3029779
Images in…
Cardiac lymphoma: ECG images pre-treatment and post-treatment
Daniel Xavier Augustine,1 Anu Garg,1 and Christopher Knechtli2
1Department of Cardiology, RUH Bath NHS Foundation Trust, Bath, UK
2Department of Haematology, RUH Bath NHS Foundation Trust, Bath, UK
Correspondence to Daniel Xavier Augustine, dxaugustine/at/hotmail.com
The chest radiograph demonstrating cardiomegaly and severe widening of the mediastinum (figure 1) is from a 55-year-old lady who presented with several months of breathlessness. Her ECG revealed Mobtiz type II second-degree heart block.
Figure 1
Figure 1
Chest x-ray on admission.
A 2-year history of pruritus was noted. CT scan revealed mediastinal lymphadenopathy.
Transthoracic ECG showed thickening of the atrial septum consistent with an infiltrative process. It extended through the tricuspid valve and into the right ventricular outflow tract (figure 2, upper panel). The infiltration was also seen to encase the aorta (figure 2, upper panel).
Figure 2
Figure 2
ECG pre-chemotherapy (upper panel) and post-chemotherapy (lower panel).
Biopsy of the mediastinal nodes yielded a histological diagnosis of nodular sclerosing Hodgkin's disease. Due to concerns relating to the possibility of cardiac rupture, treatment was initiated in the form of prednisolone 50 mg/m2 daily for 11 days prior to adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy.
Six months later, following eight cycles of ABVD chemotherapy, repeat ECG has shown remarkable regression of the Hodgkin's disease (fig 2, lower panel).
Learning points
  • Autopsy series show that cardiac invasion by non-Hodgkin's lymphomas is as high as 25%,1 whereas cardiac involvement by Hodgkin's disease is distinctly rare.2
  • This case is more unusual in that the cardiac involvement by Hodgkin's disease has caused heart block.
  • Pruritus is a feature in >25% of patients presenting with Hodgkin's disease.3 Earlier consideration of this may have avoided the ensuing cardiac complications.
Footnotes
Competing interests None.
Patient consent Obtained.
References
1. Roberts WC, Glancy DL, DeVita VT., Jr Heart in malignant lymphoma (Hodgkin's disease, lymphosarcoma, reticulum cell sarcoma and mycosis fungoides). A study of 196 autopsy cases. Am J Cardiol 1968;22:85–107. [PubMed]
2. Filly R, Bland N, Castellino RA. Radiographic distribution of intrathoracic disease in previously untreated patients with Hodgkin's disease and non-Hodgkin's lymphoma. Radiology 1976;120:277–81. [PubMed]
3. Cavalli F. Rare syndromes in Hodgkin's disease. Ann Oncol 1998;9(Suppl 5):S109–13. [PubMed]
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