Background: STEMI is a life threatening condition that results from abrupt coronary artery occlusion resulting in trans-mural myocardial injury. Most common causes of STEMI include erosion of vulnerable atherosclerotic coronary plaque with super imposed thrombus, coronary vasospasm or thromboembolic occlusion of coronary arteries. Here-in we present a very rare case of STEMI that occurred due to myopericardial invasion by a large B-cell lymphoma.
Case: A 53 years old Caucasian male with history of hyperlipidemia, diabetes, paroxysmal atrial fibrillation, stroke and diffuse large B cell lymphoma with mediastinal involvement, presented to our hospital with chest pain. Pain was sharp, left-sided, 7/10 in intensity, intermittent and had been going on for few days. Physical exam was unremarkable. Initial troponin was 0.40 ng/ml. ECG showed ST segment elevation in inferior and anterolateral leads (Fig a). Patient was emergently taken for coronary angiogram (CA) and possible PCI. Surprisingly CA did not reveal any obstructive coronary stenosis. Transthoracic echocardiogram showed hypokinesis of apical, anterior and infero-lateral wall segments. Considering patient’s ongoing symptoms and history of mediastinal involvement of lymphoma a cardiac MRI (CMR) was ordered. CMR showed a large heterogeneous mass infiltrating into pericardium, apical, infero-lateral and apical septal wall of left ventricle (Fig b). Patient was referred to oncology for further care of his advance B-cell lymphoma.
Discussion: Cardiac involvement by lymphoma is rare. STEMI caused by invasive lymphoma is even more uncommon. Myocardial infarction in the setting of invasive malignancy can be caused by combination of ischemic infarction, altered oxygen consumption and tumor embolization of coronary arteries. Here-in we present an extremely rare case of STEMI that likely resulted from abnormal myocardial oxygen consumption due to invasion of ventricular wall by aggressive B-cell lymphoma.