INTRODUCTION:We report a case of acute pericardial tamponade in a patient being treated for multiple myleoma. At the time of emergency mediastinal exploration, a laceration of the left anterior descending artery was discovered and repaired. The location of the laceration corresponded to a plasmacytoma on the left 4th rib.
CASE PRESENTATION:A 55-year-old male presented with stage IIIA IgA kappa myeloma that progressed after dexamethasone and thalidomide therapy. Early in his treatment course, a computed tomography (CT) scan revealed a plasmacytoma on his left fourth rib adjacent to the anterior interventricular septum and he received radiation therapy (see Figure 1). His past medical history was otherwise unremarkable. Medications included lansoprazole, acyclovir, bupropion, fluconazole, fluoxetine, tamsulosin, trimethoprim-sulfamethoxazole, and aspirin. He did not smoke tobacco. He was undergoing and responding to salvage chemotherapy with the hyper-CVAD (doxorubicin, vincristine, dexamethasone and cyclophosphamide) regimen. Prior to his discharge from the hospital after his second cycle of chemotherapy, he became hypotensive and lost consciousness. On arrival of the code team, the patient was supine, awake and alert. He was tachycardic and hypotensive with cold skin, a weak pulse and pulsus paradoxus. He had poor response to fluid boluses and vasopressor therapy. An echocardiogram revealed a pericardial clot and impeded right ventricular filling. He underwent emergent mediastinal exploration with identification and evacuation of a 2000 mL pericardial hematoma. A 1×1 mm laceration on the distal left anterior descending artery was found to be actively bleeding and was repaired. There were no changes on electrocardiogram and wall motion remained normal on transesophageal echocardiogram after the procedure. A CT of the chest 2 months previously revealed a 5×5 cm soft tissue mass and associated destructive lesion of the left anterior 4th rib (see Figure 1). The position of this mass corresponded to the coronary artery defect. The patient had an uneventful immediate postoperative course but did require readmissions to the hospital for a pulmonary embolus requiring anticoagulation and placement of an inferior vena cva (IVC) umbrella. Eventually, he was able to complete his chemotherapy course, undergo autologous stem cell transplantation and is in complete remission, one year from the event.
DISCUSSIONS:Multiple myeloma is a plasma cell malignancy that can involve skeletal bone. We have had two multiple myeloma patients with pericardial tamponade from malignant pericardial effusion. Additionally, we identified 21 reports of pericardial involvement with myeloma1, but did not find any reports of coronary artery erosion from a plasmacytoma. Ironically, the patient’s dramatic response to radiation and cytolytic therapy may have precipitated his coronary artery injury and life-threatening complication. Prompt identification of pericardial tamponade and surgical intervention were critical in the successful management of this patient’s condition.
CONCLUSION:This case highlights an unusual complication of a plasmacytoma of the rib.
DISCLOSURE:Nicole Alexander, None.